Do treatment and illness beliefs influence adherence to medication in patients with bipolar affective disorder? A preliminary cross-sectional study. Eur Psychiatry. 2010;25:216-219. [PMID: 20005683 DOI: 10.1016/j.eurpsy.2009.09.003]

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.

Validation of the Revised Illness Perception Questionnaire of Obstructive Sleep Apnea among Elderly Chinese in the General Population

PURPOSE

The prevalence of under-diagnosis among individuals with obstructive sleep apnea (OSA) is alarming, and may be associated with perceptions regarding OSA. To facilitate future studies on OSA, this study validated the revised version of the Illness Perception Questionnaire (IPQ-R) for OSA in a general population.

METHODS

A random anonymous population-based telephone survey interviewed 580 adults aged ≥ 50 years in Hong Kong, who self-reported not having been told by doctors as having OSA, from February 5 to March 19, 2021.

RESULTS

The confirmatory factor analysis identified a modified 7-factor model (i.e., timeline chronic, consequence, personal control, treatment control, illness coherence, timeline cyclical, and emotional representation) that showed satisfactory model fit index and internal consistency. Nine items were removed from the original version because of low factor loadings. No floor and ceiling effects were observed. Convergent validity was supported by the positive associations between the consequence subscale with perceived negative outcomes of OSA and between the illness coherence subscale and perceived understanding of OSA symptoms. The participants tended to endorse the items of timeline chronic, treatment control, and illness coherence but not with those of emotional representations. The mean scores of the IPQ-R subscales differed by age and education level.

CONCLUSION

The modified IPQ-R of OSA showed acceptable psychometric properties. It is applicable to assessing illness perceptions of OSA in the Chinese general population aged ≥ 50 years not having received OSA diagnosis. The validated tool would support future studies and health practices related to OSA.

A randomized controlled trial of customized adherence enhancement (CAE-E): study protocol for a hybrid effectiveness-implementation project

BACKGROUND

Mood-stabilizing medications are a cornerstone of treatment for people with bipolar disorder, though approximately half of these individuals are poorly adherent with their medication, leading to negative and even severe health consequences. While a variety of approaches can lead to some improvement in medication adherence, there is no single approach that has superior adherence enhancement and limited data on how these approaches can be implemented in clinical settings. Existing data have shown an increasing need for virtual delivery of care and interactive telemedicine interventions may be effective in improving adherence to long-term medication.

METHODS

Customized adherence enhancement (CAE) is a brief, practical bipolar-specific approach that identifies and targets individual patient adherence barriers for intervention using a flexibly administered modular format that can be delivered via telehealth communications. CAE is comprised of up to four standard treatment modules including Psychoeducation, Communication with Providers, Medication Routines, and Modified Motivational Interviewing. Participants will attend assigned module sessions with an interventionist based on their reasons for non-adherence and will be assessed for adherence, functioning, bipolar symptoms, and health resource use across a 12-month period. Qualitative and quantitative data will also be collected to assess barriers and facilitators to CAE implementation and reach and adoption of CAE among clinicians in the community.

DISCUSSION

The proposed study addresses the need for practical adherence interventions that are effective, flexible, and designed to adapt to different settings and patients. By focusing on a high-risk, vulnerable group of people with bipolar disorder, and refining an evidence-based approach that will integrate into workflow of public-sector care and community mental health clinics, there is substantial potential for improving bipolar medication adherence and overall health outcomes on a broad level.

TRIAL REGISTRATION

The study was registered on ClinicalTrials.gov NCT04622150 on November 9, 2020.

Patient Factors Influencing Outpatient Retention in Patients with Affective and Anxiety Disorders: A Retrospective Study

OBJECTIVE

The aim of the present study is to identify the factors that affect retention in outpatients with psychiatric disorders as indicators of treatment adherence, including Minnesota Multiphasic Personality Inventory (MMPI) scores.

METHODS

The medical records of 146 patients diagnosed with major depressive disorder, bipolar disorder, or anxiety disorder for at least 10 years and discharged were retrospectively reviewed in the present study. The subjects were categorized based on the duration of outpatient treatment as < 6 months (L6) or ≥ 6 months (M6) groups and reclassified as < 36 months (L36) and ≥ 36 months (M36) groups. The demographic, clinical, and personality characteristics of the groups were compared.

RESULTS

Patients in M6 and M36 groups were more likely to have a higher educational level compared with those in the L6 and L36 groups, respectively. Patients in the M6 group showed significantly lower hypomania (Ma) scores on the MMPI test than did patients in the L6 group.

CONCLUSION

The association between high Ma score on the MMPI test and early discontinuation of treatment suggests that impulsivity, hostility, and disinhibition confer higher risk of nonadherence.

Mapping modifiable determinants of medication adherence in bipolar disorder (BD) to the theoretical domains framework (TDF): a systematic review

BACKGROUND

Around 40% of people with bipolar disorder (BD) are non-adherent to medication leading to relapse, hospitalisation and increased suicide risk. Limited progress in addressing non-adherence may be partly attributable to insufficient understanding of the modifiable determinants of adherence that require targeting in interventions. We synthesised the modifiable determinants of adherence in BD and map them to the theoretical domains framework (TDF).

METHOD

We searched CINAHL, Cochrane Library, Embase, LILACS, Medline, PsychINFO and PubMed until February 2020. We included studies reporting modifiable determinants of adherence in BD. Two reviewers independently screened studies, assessed quality, extracted modifiable determinants and mapped them to TDF.

RESULTS

We included 57 studies involving 32 894 participants. Determinants reported by patients spanned 11 of the 14 TDF domains compared to six domains represented by clinician/researcher. The TDF domains most commonly represented (% and example) in studies were: 'Environmental context and resources' (63%, e.g. experiencing side effects), 'Beliefs about consequences' (63%, e.g. beliefs about medication effects), 'Knowledge' (40%, e.g. knowledge about disorder), 'Social influences' (33%, e.g. support from family/clinicians), 'Memory, attention and decision processes' (33%, e.g. forgetfulness), 'Emotion' (21%, e.g. fear of addiction) and 'Intentions' (21%, e.g. wanting alternative treatment). 'Intentions', 'Memory, attention and decision processes' and 'Emotion' domains were only reported by patients but not clinicians.

CONCLUSIONS

Clinicians may be underappreciating the full range of modifiable determinants of adherence and thus not providing adherence support reflective of patients' needs. Reporting of modifiable determinants in behavioural terms facilitates developing theory-based interventions to address non-adherence in BD.

Assessment of illness representations in mental disorders: A mini review

Health beliefs, and especially illness representations, have been widely used to understand clinical outcomes and psychosocial adjustment in people with physical diseases. However, this area of research has been under-explored in the field of mental health, and the few studies that have been conducted have used very different methods. Therefore, the aim of our study was to identify the tools and methods that have been used to evaluate illness representations in psychiatry. To this end, a mini review has been conducted and 58 articles were retained. This mini review highlights that the quantitative method is the most used, and that the scales mobilised are often adapted for the study, but not validated. Indeed, multiple modifications and adaptations have been made by the authors (e.g. deletion of subscales, addition of items), which lead to questions about the reliability of what is measured. In the future, it is essential to have a validated generic tool for mental disorders, which could be based on the Illness perceptions questionnaire for schizophrenia.

Psychological factors involved in psychopharmacological medication adherence in mental health patients: A systematic review

BACKGROUND

Psychopharmacological medication adherence is essential for psychiatric patients' treatment and well-being.

OBJECTIVE

This review aimed to identify psychological factors related to health control that have been linked to psychopharmacological medication adherence in psychiatric patients.

METHODS

A literature search was performed through the databases Medline, PubMed, PsycINFO, and Google Scholar to identify relevant studies published before October 15th, 2019. Articles published in peer-reviewed journals that analyzed the psychological factors of health belief and health control involved in psychopharmacological medication adherence in a psychiatric population were included.

RESULTS

The search identified 124 potentially relevant papers, 29 of which met the eligibility criteria. The final sample was 222 adolescents, most with a diagnosis of attention deficit/hyperactivity disorder (ADHD), and 6139 adults diagnosed especially with schizophrenia spectrum disorder, bipolar disorder, or depressive disorder. Results suggested that medication adherence is associated with health beliefs and psychological variables, such as self-efficacy and locus of control. Family support was also positively related to medication adherence.

CONCLUSION

Psychopharmacological medication adherence requires a consideration of multicausality, which depends on sociodemographic, clinical, and psychological factors.

PRACTICE IMPLICATIONS

These findings should be considered in the development and implementation of psychological interventions focused on self-control and family support.

The psychometric properties of the Revised Illness Perception Questionnaire (IPQ-R) regarding Internet gaming disorder in a general population of Chinese adults

BACKGROUND AND AIMS

Internet gaming disorder (IGD) has been recognized as a mental illness. Cognitive and emotional illness representations affect coping and health outcomes. Very little is known about such perceptions related to IGD, in both general and diseased populations. This study examined the psychometric properties of the Revised Illness Perception Questionnaire (IPQ-R) for IGD in a general population that included mostly non-cases while a small proportion of the sample was IGD cases.

METHODS

An anonymous cross-sectional telephone survey was conducted in a random sample of 1,501 Chinese community-dwelling adults (41.3% male; mean age = 40.42, SD = 16.85) in Macao, China.

RESULTS

The confirmatory factor analysis identified a modified 6-factor model (i.e., timeline cyclical, consequences, personal control, treatment control, illness coherence, and emotional representations) of 26 items that showed satisfactory model fit and internal consistency. Criterion-related validity was supported by the constructs' significant correlations with stigma (positive correlations: timeline cyclical, consequence, emotional representations; negative correlations: illness coherence). Ever-gamers, compared to never-gamers, reported higher mean scores in the subscales of personal control and illness coherence, and lower mean scores in time cyclical, consequence, and emotional representations. Among the sampled gamers, probable IGD cases were more likely than non-IGD cases to perceive IGD as cyclical and involved more negative emotions.

CONCLUSIONS

This study shows that the revised 26-item version of IPQ-R is a valid instrument for assessing illness representation regarding IGD in a general population of Chinese adults. It can be used in future research that examines factors of incidence and prevention related to IGD.

Relationship Between Illness Representations, Psychosocial Adjustment, and Treatment Outcomes in Mental Disorders: A Mini Review

Understanding and improving the psychosocial adjustments (e.g., quality of life, depression) and treatment outcomes (e.g., adherence, beliefs about treatments) of people with mental disorders are major health issues. The self-regulation model (SRM) postulates that illness representations play a central role on adjustment and treatment of people with physical illnesses. Recently, the SRM has been used with people with mental disorders. However, the manifestations of somatic and psychiatric disorders can be very different. Therefore, the use of SRM in the field of mental health is very complex. This difficulty, as well as the growing interest for illness representations in the field of mental health, justifies the utility to conduct a review on this topic. The current review shows that illness representations are related to psychosocial adjustment and/or treatment outcomes for people with various mental disorders [e.g., psychotic disorders, mood disorder, posttraumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD)]. However, some limitations to the applicability of SRM to mental disorders have been highlighted. These limitations should be considered in future studies.

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.

Psychotropic medication non-adherence among patients with severe mental disorder attending at Bahir Dar Felege Hiwote Referral hospital, north west Ethiopia, 2017

Objective

Medication non-adherence is a major public health problem that has been called an “invisible epidemic”. Globally, non-adherence rates among patients with severe mental illness ranged between 30 and 65%. It greatly increases the risk of illness exacerbation and hospitalizations. However, there is a paucity of studies examining treatment non-adherence and its associated factors among patients with severe mental disorder. Therefore, this study was aimed at determining the magnitude of medication non-adherence and associated factors among patients with severe mental disorder.

Results

A total of 409 study subjects were participated making a response rate of 92%. The overall prevalence of medication non-adherence was found to be 55.2% (95%, CI; 49.9%, 60.2%). Study participants whose age group of (25–34) [AOR = 3.04 (95% CI 1.27, 7.29)], study subjects taking their medication twice per day [AOR = 4.60 (95% CI 2.25, 9.43)], no social support [AOR = 4.4 (95% CI 1.78, 11.08)] and no insight for their treatment [AOR = 5.88 (CI 2.08, 16.59)] were significantly associated with medication non-adherence. The result of this study showed that non-adherence among patients with severe mental disorder was found to be high. Psychiatry health care providers have to consider the frequency of medication become once per day, continual awareness creation among professionals and engaging significant others for good social support system and continual treatment alliance is strongly commended for adherence.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4126-2) contains supplementary material, which is available to authorized users.

Illness Beliefs, Treatment Beliefs and Information Needs as Starting Points for Patient Information: The Evaluation of an Intervention for Patients with Depression

Patients with depression are often dissatisfied with disease- and therapy-related information. The objective of this study was to evaluate an intervention that applied the Common Sense Model to the provision of information during inpatient rehabilitation for patients with depression. The intervention was evaluated in a sequential control group design. Analyses of covariance were used to assess differences between the control and intervention groups. Changes with respect to illness and treatment beliefs (personal control, treatment control, coherence and concerns about medicines), satisfaction with information about medicines, illness and rehabilitation, and depressive burden were selected as primary outcome measures. We observed significant between-group differences indicating the intervention group's superiority in terms of satisfaction with information regarding medicines. However, the two groups' changes during rehabilitation did not differ in terms of the other outcomes. The intervention resulted in patients judging that their medication information needs had been more thoroughly fulfilled than those patients who received care-as-usual information. However, the intervention did not prove to be effective when the other outcome variables are considered. Taken together and bearing in mind the limitations of our study-particularly the non-randomised design-our results should be replicated in a randomised controlled trial.

Illness perceptions and adherence in bipolar disorder: An exploratory study

BACKGROUND

According to the Self-Regulation Model, illness perceptions influence an individual's coping (such as the taking of treatment) and emotional response to their illness. Emerging research suggests that this model could be used to explore illness perceptions in mental health. The aim of this exploratory study is, firstly, to measure and describe illness perception in French patients with a bipolar diagnosis and, secondly, to explore associations between illness perceptions and adherence in this population.

METHOD

Thirty-eight French patients with bipolar disorder completed the Illness Perception Questionnaire for Schizophrenia (except the identity dimension). We measured medication adherence with the Medication Adherence Rating Scale.

RESULTS

Our results showed that patients with high perceptions concerning treatment control, low perceptions of negative emotions of their mental illness, low perception of consequences and high comprehension of their disorder had a better adherence.

CONCLUSIONS

Illness perceptions can provide a framework for understanding adherence in bipolar disorder, and the findings could have important clinical and research implications.

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.

Common sense model of mental illness: Understanding the impact of cognitive and emotional representations of mental illness on recovery through the mediation of self-stigma

The present study applied the common sense model to understand the underlying mechanism of how cognitive and emotional representations of mental illness among people in recovery of mental illness would impact their endorsement of self-stigma, and how that would, in turn, affect clinical and personal recovery. A cross-sectional survey was administered to 376 people in recovery. Participants were recruited from seven public specialty outpatient clinics and substance abuse assessment clinics across various districts in Hong Kong. They were asked to report their perception towards their mental illness, self-stigma, symptom severity, and personal recovery. The results of structural equation modeling partially supported the hypothesized mediation model indicating that controllability, consequences, and emotional concern of mental illness, but not cause, timeline, and identity, were associated with self-stigma, which was subsequently negatively associated with clinical and personal recovery. The present study demonstrated the mediating role of self-stigma in the relationship between individuals' illness representations towards their mental illness and their recovery. Illness management programs aimed at addressing the maladaptive mental illness-related beliefs and emotions are recommended. Implications on developing self-directed and empowering mental health services are discussed.

Treatment-adherence in bipolar disorder: A patient-centred approach

About half of the patients diagnosed with bipolar disorder (BD) become non-adherent during long-term treatment, a rate largely similar to other chronic illnesses and one that has remained unchanged over the years. Non-adherence in BD is a complex phenomenon determined by a multitude of influences. However, there is considerable uncertainty about the key determinants of non-adherence in BD. Initial research on non-adherence in BD mostly limited itself to examining demographic, clinical and medication-related factors impacting adherence. However, because of inconsistent results and failure of these studies to address the complexities of adherence behaviour, demographic and illness-related factors were alone unable to explain or predict non-adherence in BD. This prompted a shift to a more patient-centred approach of viewing non-adherence. The central element of this approach includes an emphasis on patients’ decisions regarding their own treatment based on their personal beliefs, life circumstances and their perceptions of benefits and disadvantages of treatment. Patients’ decision-making processes are influenced by the nature of their relationship with clinicians and the health-care system and by people in their immediate environment. The primacy of the patient’s perspective on non-adherence is in keeping with the current theoretical models and concordance-based approaches to adherence behaviour in BD. Research over the past two decades has further endorsed the critical role of patients’ attitudes and beliefs regarding medications, the importance of a collaborative treatment-alliance, the influence of the family, and the significance of other patient-related factors such as knowledge, stigma, patient satisfaction and access to treatment in determining non-adherence in BD. Though simply moving from an illness-centred to a patient-centred approach is unlikely to solve the problem of non-adherence in BD, such an approach is more likely to lead to a better understanding of non-adherence and more likely to yield effective solutions to tackle this common and distressing problem afflicting patients with BD.

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.

The necessity-concerns framework predicts adherence to medication in multiple illness conditions: A meta-analysis

OBJECTIVE

This meta-analysis investigated whether beliefs in the necessity and concerns of medicine and the necessity-concerns differential are correlated with medication adherence on a population level and in different conditions.

METHODS

An electronic search of Web of Science, EMBASE, PubMed and CINAHL was conducted for manuscripts utilising the Beliefs about Medicines Questionnaire and comparing it to any measure of medication adherence. Studies were pooled using the random-effects model to produce a mean overall effect size correlation. Studies were stratified for condition, adherence measure, power and study design.

RESULTS

Ninety-four papers were included in the meta-analysis. The overall effect size(r) for necessity, concerns, and necessity-concerns differential was 0.17, -0.18 and 0.24 respectively and these were all significant (p<0.0001). Effect size for necessity was stronger in asthma and weaker in the cardiovascular group compared to the overall effect size.

CONCLUSION

Necessity and concerns beliefs and the necessity-concerns differential were correlated with medication adherence on a population level and across the majority of included conditions. The effect sizes were mostly small with a magnitude comparable to other predictors of adherence.

PRACTICE IMPLICATIONS

This meta-analysis suggests that necessity and concern beliefs about medicines are one important factor to consider when understanding reasons for non-adherence.

Family Access to a Dentist Study (FADS): A multi-center randomized controlled trial

INTRODUCTION

Many low-income parent/caregivers do not understand the importance of cavity-free primary (baby) teeth and the chronic nature of dental caries (tooth decay). As a consequence, dental preventive and treatment utilization is low even when children are screened in schools and referred for care. This study aims to test a referral letter and Dental Information Guide (DIG) designed using the Common-Sense Model of Self-Regulation (CSM) framework to improve caregivers' illness perception of dental caries and increase utilization of care by children with restorative dental needs.

METHODS

A multi-site randomized controlled trial with caregivers of Kindergarten to 4th grade children in urban Ohio and rural Washington State will compare five arms: (1) CSM referral letter alone; (2) CSM referral letter+DIG; (3) reduced CSM referral letter alone; (4) reduced CSM referral letter+DIG; and (5) standard (control) referral. At baseline, children will be screened at school to determine restorative dental needs. If in need of treatment, caregivers will be randomized to study arms and an intervention packet will be sent home. The primary outcome will be dental care based on a change in oral health status by clinical examination 7 months post-screening (ICDAS sealant codes 1 and 2; restoration codes 3-8; extraction). Enrollment commenced summer 2015 with results in summer 2016.

CONCLUSION

This study uses the CSM framework to develop and test behavioral interventions to increase dental utilization among low-income caregivers. If effective this simple intervention has broad applicability in clinical and community-based settings.

Illness perception of dropout patients followed up at bipolar outpatient clinic, Turkey

Dropout is a common problem in the treatment of psychiatric illnesses including bipolar disorders (BD). The aim of the present study is to investigate illness perceptions of dropout patients with BD. A cross sectional study was done on the participants who attended the Mood Disorder Outpatient Clinic at least 3 times from January 2003 through June 2008, and then failed to attend clinic till to the last one year, 2009, determined as dropout. Thirty-nine dropout patients and 39 attendent patients with BD were recruited for this study. A sociodemographic form and brief illness perception questionnaire were used to capture data. The main reasons of patients with BD for dropout were difficulties of transport (31%), to visit another doctor (26%), giving up drugs (13%) and low education level (59%) is significant for dropout patients. The dropout patients reported that their illness did not critically influence their lives, their treatment had failed to control their illnesses, they had no symptoms, and that their illness did not emotionally affect them. In conclusion, the nonattendance of patients with serious mental illness can result in non-compliance of therapeutic drug regimens, and a recurrence of the appearance symptoms. The perception of illness in dropout patients with BD may be important for understanding and preventing nonattendance.

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

OBJECTIVES

While medication treatment is necessary for the successful management of bipolar disorder (BD), non-adherence rates are up to 60%. Although medication attitudes are believed to be relevant to adherence behavior, few studies have investigated the trajectories of adherence change. This study evaluated attitudinal correlates of adherence conversion in 86 poorly adherent individuals with BD.

METHODS

This secondary analysis pooled data from two uncontrolled prospective trials of customized adherence enhancement (CAE), a psychosocial intervention delivered over 4-6 weeks. Poor adherence was defined as missing at least 20% of prescribed BD medication based on the self-reported Tablets Routine Questionnaire (TRQ). The sample was dichotomized into converters who achieved good adherence (N=44) and non-converters who remained poorly adherent (N=21). Converters vs. non-converters were compared on adherence, attitudes, and symptoms at baseline, 6 weeks and 3 months.

RESULTS

At baseline, converters and non-converters were similar demographically and clinically, but converters were less non-adherent (32% doses missed) than non-converters (59% missed). At 6 weeks, converters had better attitudes than non-converters. At 3 months, converters maintained improvements, but group differences were less pronounced due to some improvement in non-converters. Converters had better adherence at 3 months and trajectories differed for the groups on attitudes. Symptoms gradually improved for both converters and non-converters.

CONCLUSIONS

Over two-thirds of poorly adherent BD patients who received CAE converted to good adherence. Improved medication attitudes may be a driver of improved adherence behavior and ultimately reduce BD symptoms.

Mood disorders medications: predictors of nonadherence - review of the current literature

Studies have shown that there are several factors that predict nonadherence among patients with mood disorders. The aim of the present review is to identify the predictors of nonadherence among these patients. A careful review of the literature was conducted investigating several potential predictors of nonadherence among patients with mood disorders. A total of 217 relevant articles from peer-reviewed journals were considered, and articles that met our inclusion criteria (n = 54) were selected for this review. The authors identified several predictors of nonadherence among patients with mood disorders including younger age (below 40 years old), comorbidity with substance use and personality disorders, patients' beliefs, poor insight, illness severity, treatment-related side effects, specific features of the disease and a poor therapeutic alliance. Substance use disorder and illness severity are significant predictors of nonadherence especially in patients with bipolar disorder; whereas, treatment side effects are of primary importance for depressive disorder. The authors could not carry out a meta-analysis given that the studies considered in this review assessed patients at different time points and included different measurements of nonadherence. Moreover, articles cited in this review may reflect the authors' choice, and the authors did not investigate the adherence to a specific class of drugs commonly used in the management of mood disorders. Given the high social, clinical and economic impact of nonadherence among patients who are affected by mood disorders, it is critical to recognize patients at high risk of nonadherence in order to inform future strategies to examine and improve adherence to treatment. Further research is needed to clarify this issue.

Understanding patients' adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the Necessity-Concerns Framework

BACKGROUND

Patients' beliefs about treatment influence treatment engagement and adherence. The Necessity-Concerns Framework postulates that adherence is influenced by implicit judgements of personal need for the treatment (necessity beliefs) and concerns about the potential adverse consequences of taking it.

OBJECTIVE

To assess the utility of the NCF in explaining nonadherence to prescribed medicines.

DATA SOURCES

We searched EMBASE, Medline, PsycInfo, CDSR/DARE/CCT and CINAHL from January 1999 to April 2013 and handsearched reference sections from relevant articles.

STUDY ELIGIBILITY CRITERIA

Studies using the Beliefs about Medicines Questionnaire (BMQ) to examine perceptions of personal necessity for medication and concerns about potential adverse effects, in relation to a measure of adherence to medication.

PARTICIPANTS

Patients with long-term conditions.

STUDY APPRAISAL AND SYNTHESIS METHODS

Systematic review and meta-analysis of methodological quality was assessed by two independent reviewers. We pooled odds ratios for adherence using random effects models.

RESULTS

We identified 3777 studies, of which 94 (N = 25,072) fulfilled the inclusion criteria. Across studies, higher adherence was associated with stronger perceptions of necessity of treatment, OR = 1.742, 95% CI [1.569, 1.934], p<0.0001, and fewer Concerns about treatment, OR = 0.504, 95% CI: [0.450, 0.564], p<0.0001. These relationships remained significant when data were stratified by study size, the country in which the research was conducted and the type of adherence measure used.

LIMITATIONS

Few prospective longitudinal studies using objective adherence measures were identified.

CONCLUSIONS

The Necessity-Concerns Framework is a useful conceptual model for understanding patients' perspectives on prescribed medicines. Taking account of patients' necessity beliefs and concerns could enhance the quality of prescribing by helping clinicians to engage patients in treatment decisions and support optimal adherence to appropriate prescriptions.

The association of illness perceptions with depressive symptoms and general psychological distress in parents of an offspring with autism spectrum disorder

BACKGROUND

Raising a child with an autism spectrum disorder (ASD) is a severe stressor and parents often present high levels of depression. Depression is associated with illness perceptions but this association has not been studied in parents of ASD offspring.

OBJECTIVE

We aimed to assess the prevalence of psychological distress symptoms and their associations with illness perceptions in parents with an ASD offspring.

METHODS

In 111 parents of ASD offspring we assessed depressive symptoms (PHQ-9), illness perceptions (B-IPQ) and general psychological distress (GHQ-28). Multiple linear and logistic regressions were used to assess their independent associations.

RESULTS

The prevalence of parental clinically significant depressive symptoms was 34.2%, while 55% presented clinically significant levels of general psychological distress. Younger parents and those with lower financial resources had greater psychological distress and more severe depressive symptoms. Parents felt that the condition impacted their lives and believed it would be chronic. Their beliefs about the consequences and the chronicity of the disorder were significant independent correlates of their psychological distress and depressive symptoms severity.

CONCLUSIONS

These findings indicate that a remarkable proportion of parents with an ASD offspring present clinically significant depressive symptoms, which were associated with illness perceptions relevant to the consequences and the chronicity of the disorder. Our data encourage psychotherapeutic interventions aiming to support parents to deal with the consequences and chronicity of their offspring's disorder, in order to reduce parental psychological distress.

Association between therapeutic alliance, care satisfaction, and pharmacological adherence in bipolar disorder

OBJECTIVES

We sought to understand the association of specific aspects of care satisfaction, such as patients' perceived relationship with their psychiatrist and access to their psychiatrist and staff, and therapeutic alliance with participants' likelihood to adhere to their medication regimens among patients with bipolar disorder.

METHODS

We examined data from the multicenter Systematic Treatment Enhancement Program for Bipolar Disorder, an effectiveness study investigating the course and treatment of bipolar disorder. We expected that participants (n = 3037) with positive perceptions of their relationship with their psychiatrist and quality of psychopharmacologic care, as assessed by the Helping Alliance Questionnaire and Care Satisfaction Questionnaire, would be associated with better medication adherence. We utilized logistic regression models controlling for already established factors associated with poor adherence.

RESULTS

Patients' perceptions of collaboration, empathy, and accessibility were significantly associated with adherence to treatment in individuals with bipolar disorder completing at least 1 assessment. Patients' perceptions of their psychiatrists' experience, as well as of their degree of discussing medication risks and benefits, were not associated with medication adherence.

CONCLUSIONS

Patients' perceived therapeutic alliance and treatment environment impact their adherence to pharmacotherapy recommendations. This study may enable psychopharmacologists' practices to be structured to maximize features associated with greater medication adherence.

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 2013

The Canadian Network for Mood and Anxiety Treatments published guidelines for the management of bipolar disorder in 2005, with updates in 2007 and 2009. This third update, in conjunction with the International Society for Bipolar Disorders, reviews new evidence and is designed to be used in conjunction with the previous publications.The recommendations for the management of acute mania remain largely unchanged. Lithium, valproate, and several atypical antipsychotic agents continue to be first-line treatments for acute mania. Monotherapy with asenapine, paliperidone extended release (ER), and divalproex ER, as well as adjunctive asenapine, have been added as first-line options.For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, as well as olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. Lurasidone monotherapy and the combination of lurasidone or lamotrigine plus lithium or divalproex have been added as a second-line options. Ziprasidone alone or as adjunctive therapy, and adjunctive levetiracetam have been added as not-recommended options for the treatment of bipolar depression. Lithium, lamotrigine, valproate, olanzapine, quetiapine, aripiprazole, risperidone long-acting injection, and adjunctive ziprasidone continue to be first-line options for maintenance treatment of bipolar disorder. Asenapine alone or as adjunctive therapy have been added as third-line options.

Exploring the beliefs of heart failure patients towards their heart failure medicines and self care activities

AIM

To identify Heart Failure patients' beliefs towards their medications and how these beliefs relate to adherence.

METHOD

Patients attending a multi-disciplinary, community based heart failure clinic on the Gold Coast, Australia were interviewed using a questionnaire composed of fours parts: repertory grid technique; Beliefs About Medicines Questionnaire (BMQ); Medicines Adherence Reporting Scale (MARS); demographic details. Patients were divided into those categorised as adherent (MARS score ≥ 23) and those categorised as non-adherent (MARS score < 23). Necessity beliefs scores from BMQ and the frequency of statements generated from the repertory grid portion of the questionnaire were compared between these two groups.

RESULTS

Forty-three patients were interviewed with a mean age (±SD) of 64 (±17) years and thirty-six (83.7 %) were male. Thirty-seven (86.0 %) patients were categorised as adherent; the remaining six (14.0 %) as non-adherent. The 43 patients generated a total of 262 statements about their medicines. The three most common themes identified were Related to fluid (36.6 %), Helps the heart (31.7 %) and Related to weight (13.7 %). There was a significantly higher median necessity score in the adherent group compared to the non adherent group (22.0 vs. 19.5, p = 0.0272). Patients with a strong necessity score also had significantly higher self reported adherence compared to patients with a strong concerns score (21.5 vs. 18.0, p = 0.006).

CONCLUSION

This study suggests that patients with heart failure possessing a strong belief in the necessity of their treatment regimen are more likely to demonstrate better adherence.

Illness beliefs and treatment beliefs as predictors of short and middle term outcome in depression

The article investigates whether illness beliefs and beliefs about rehabilitation are predictors of short and middle term outcome in depression even when adjustments are made for variables, which are known to be predictors of the course of depression. Within the context of a non-controlled prospective study design, data were analyzed using forced entry hierarchical multiple regression analyses. The sample comprised N = 98 patients. Adjusting for a range of sociodemographic and medical predictors, illness beliefs and beliefs about rehabilitation predict outcome in depression. Illness beliefs and beliefs about rehabilitation are relevant starting points for designing patient-oriented interventions.