Beliefs about medication predict the misattribution of a common symptom as a medication side effect--Evidence from an analogue online study

Perceived sensitivity to medicines and medication concerns beliefs predict intentional nonadherence to antiretroviral therapy among young people living with HIV

Objective: Among the sources of antiretroviral therapy (ART) nonadherence are patient decisions to skip or stop taking their medications, often stemming from medication beliefs and concerns about side- effects. While individuals who perceive greater sensitivity to medicines may be prone to medication concerns, understanding how these factors contribute to HIV treatment adherence requires further research. The current study tested the direct and indirect effects of perceived sensitivity to medicines on intentional nonadherence to ART, and whether medication concerns mediate this association.

Methods: A sample of 418 younger (< 36 years of age) people living with HIV was recruited through community outreach to complete assessments of perceived sensitivity to medicines, medication concerns beliefs, adherence assessed by unannounced phone- based pill counts and HIV viral load, as well as monthly follow- up assessments of intentional nonadherence over a 15- month period.

Results: Analyses at baseline and prospective Poisson regression models conducted over 15- months converged to show that perceived sensitivity to medicines significantly predicted intentional nonadherence to ART through medication concerns.

Conclusions: These findings suggest that people who perceive greater sensitivity to medicines are prone to greater medication concerns that are related to intentional nonadherence. Cognitive behavioral interventions are needed to resolve medication concerns and reduce intentional nonadherence among people receiving ART.

The association of depressive symptoms and medication adherence in asthma patients: The mediation effect of medication beliefs

BACKGROUND

The significant role of depression in influencing medication beliefs, which are pivotal cognitive factors that strongly influence medication adherence, has been established. Poor adherence to asthma-controlled medication poses an significant barrier to achieving optimal asthma management.

OBJECTIVE

To explore the potential mediating effects of medication beliefs on the relationship between depressive symptoms and medication adherence in patients with asthma.

METHODS

Demographic and clinical characteristics, depressive symptoms, medication adherence, and medication beliefs were collected using questionnaires. Structural equation modeling, was utilized to model medication beliefs as mediators in the relationship between depressive symptoms and medication adherence. Bootstrapping was performed to analyze the mediation- and contrast-specific indirect effects of the two medication beliefs.

RESULTS

Among the patients who participated in the study, 29.6 % with depressive symptoms were more prone to poor adherence and exhibited skepticism toward asthma medications. Depression had a direct effect (direct effect = -0.275, 95%CI: -0.369 to -0.190) and an indirect effect on adherence mediated by medication beliefs (indirect effect = -0.168, 95%CI: -0.224 to -0.121). The specific mediation effect of concern belief was stronger than that of necessity belief (difference = -0.076, 95%CI: -0.132 to -0.029).

CONCLUSION

Depressive symptoms have a direct impact on medication adherence as well as an indirect effect mediated by beliefs about medication, particularly concerns belief.

Perceptions of conflicting information about long-term medications: a qualitative in-depth interview study of patients with chronic diseases in the Swiss ambulatory care system

OBJECTIVE

Patients with multiple long-term conditions visit various healthcare professionals and are exposed to medication information from various sources causing an increased risk of patients perceiving contradictory medication information. The aims of this study are to: (1) characterise conflicting medication information perceived by patients with long-term conditions, (2) better understand the related impact on patients' medication self-management and healthcare system navigation and (3) explore ways in which such events could be prevented.

DESIGN

This study was conducted through qualitative semistructured interviews. Data were analysed using thematic analysis.

SETTING

Community pharmacies and medical centres in Geneva, Switzerland.

PARTICIPANTS

This study included outpatients from April 2019 to February 2020. Patients were included after participating in a quantitative survey of perceived conflicting information about medications for long-term diseases.

METHODS

Semistructured audiotaped interviews of 20 to 60 min following a pre-established interview guide to explore participants' perceptions of conflicting information. Interviews were transcribed verbatim, and a thematic analysis was conducted with inductive and deductive coding using MAXQDA (2018, Release 18.2.3).

RESULTS

Twenty-two patients were interviewed, until data saturation, mentioning indication or need for a medication as the main topic of conflicting information between two healthcare professionals. Perceived conflicting information often resulted from insufficient information provided and poor communication leading to confusion, doubts and medication non-adherence. Patients expected more information and more interprofessional communication on their medications. As a result of conflicting information, most participants learnt or were learning to take an active role and become partners of the healthcare providers.

CONCLUSION

The need to strengthen and improve communication and interprofessional collaborative practice among healthcare professionals and with the patient is emerging to increase the quality and consistency of information about medications, and consequently, to ensure better use and experience of medications.

Medication nonadherence: health impact, prevalence, correlates and interventions

Nonadherence to medicines is a global problem compromising health and economic outcomes for individuals and society. This article outlines how adherence is defined and measured, and examines the impact, prevalence and determinants of nonadherence. It also discusses how a psychosocial perspective can inform the development of interventions to optimise adherence and presents a series of recommendations for future research to overcome common limitations associated with the medication nonadherence literature. Nonadherence is best understood in terms of the interactions between an individual and a specific disease/treatment, within a social and environmental context. Adherence is a product of motivation and ability. Motivation comprises conscious decision-making processes but also from more 'instinctive', intuitive and habitual processes. Ability comprises the physical and psychological skills needed to adhere. Both motivation and ability are influenced by environmental and social factors which influence the opportunity to adhere as well as triggers or cues to actions which may be internal (e.g. experiencing symptoms) or external (e.g. receiving a reminder). Systematic reviews of adherence interventions show that effective solutions are elusive, partly because few have a strong theoretical basis. Adherence support targeted at the level of individuals will be more effective if it is tailored to address the specific perceptions (e.g. beliefs about illness and treatment) and practicalities (e.g. capability and resources) influencing individuals' motivation and ability to adhere.

Alternative and complementary medicine in neurological disorders and neurological disability patients: Prevalence, factors, opinions and reasons

OBJECTIVES

This cross-sectional study is aimed to investigate the prevalence of the use of complementary and alternative medicine (CAM), types of CAMs used, as well as reasons and factors found in patients with neurological diseases or neurological disability.

METHODS

An anonymous, self-administered survey was designed to collect information about demographics, personal medical history, CAM usage habits, and different opinions about CAM vs. conventional medicine (CM). The survey was applied by non-medical personnel in a rehabilitation hospital to patients older than 18 years, with a confirmed diagnosis of neurological disorder or neurological disability.

RESULTS

453 patients were included, 59.7 % were female. Mean age: 49 years (SD: 18.2). 200 patients (44.2 %) had a history of chronic diseases. Depression was found in 139 patients (30.7 %). Neurological disorders were: peripheral neuropathy: 97 (21.4 %), headache or migraine: 78 (17.2 %), neurodegenerative diseases: 69 (15.2 %) and stroke: 58 (12.8 %). 60.2 % (n = 273) had some degree of disability. Prevalence of CAM use was 36 % (n = 163). Most common CAMs were: Biological therapies: 133 (71.1 %), energy-based therapies: 63 (33.7 %) and body manipulation therapies: 51 (27.3 %). Reasons to use CAM were: "to complement the pharmacological treatment" (45 = 27.6 %), and "treatment failure with CM" (43 = 26.4 %). Finally, older age (p = 0.0280) and having a chronic disease (p = 0.0229) or depression (p < 0.001) were the factors associated with the current use of CAM.

CONCLUSION

One third of patients with neurological pathologies use CAM, the most popular type of CAM is biologic therapies. As in other pathologies, CAM use was associated with older age, history of depression, and chronic diseases. Therefore, it is suggested that physicians routinely ask patients about the use of CAM, if they need more information about CAM, and even verify the possibility of drug interactions or adverse effects.

Shedding Light on SARS-CoV-2, COVID-19, COVID-19 Vaccination, and Auditory Symptoms: Causality or Spurious Conjunction?

There are reports of associations between SARS-CoV2, COVID-19, COVID-19 vaccines, and auditory symptoms (hearing difficulty, tinnitus). However, most studies have relied on self-report and lack baseline and/or non-COVID control groups. This makes it problematic to differentiate if symptoms are associated with SARS-CoV2, COVID-19, the vaccine, psychosocial factors or recall bias. In this study, we differentiate these by comparing hearing and tinnitus survey data collected pre- and during the pandemic. The survey conducted during the pandemic asked about the onset and change in three types of symptom. Type One—known association (loss of smell, memory/concentration issues, persistent fatigue), Type Two—indeterminate association (auditory symptoms), and Type Three—no established association with COVID-19 (toothache). We hypothesized that if auditory symptoms are directly associated with COVID-19, their onset and change would be similar to Type One symptoms, but if indirectly associated (reflecting psychosocial factors and/or recall bias) would be more similar to Type Three symptoms. Of the 6,881 individuals who responded, 6% reported confirmed COVID-19 (positive test), 11% probably had COVID-19, and 83% reported no COVID-19. Those with confirmed or probable COVID-19 more commonly reported new and/or worsened auditory symptoms than those not reporting COVID-19. However, this does not imply causality because: (1) new auditory symptoms coincided with COVID-19 illness among just 1/3 of those with confirmed or probable COVID-19, and another 1/3 said their symptoms started before the pandemic—despite reporting no symptoms in the pre-pandemic survey. (2) >60% of individuals who had COVID-19 said it had affected their Type 3 symptoms, despite a lack of evidence linking the two. (3) Those with confirmed COVID-19 reported more Type 1 symptoms, but reporting of Type 2 and Type 3 symptoms did not differ between those with confirmed COVID-19 and those without COVID-19, while those who probably had COVID-19 most commonly reported these symptom types. Despite more reports of auditory symptoms in confirmed or probable COVID-19, there is inconsistent reporting, recall bias, and possible nocebo effects. Studies that include appropriate control groups and use audiometric measures in addition to self-report to investigate change in auditory symptoms relative to pre-COVID-19 are urgently needed.

Beliefs About Medicines Predict Side-Effects of Placebo Modafinil

BACKGROUND

Patients receiving placebo in clinical trials often report side-effects (nocebo effects), but contributing factors are still poorly understood.

PURPOSE

Using a sham trial of the cognition-enhancing "smart pill" Modafinil we tested whether medication beliefs and other psychological factors predicted detection and attribution of symptoms as side-effects to placebo.

METHODS

Healthy students (n = 201) completed measures assessing beliefs about medication, perceived sensitivity to medicines, negative affectivity, somatization, and body awareness; 66 were then randomized to receive Deceptive Placebo (told Modafinil-given placebo, 67 to Open Placebo (told placebo-given placebo, and 68 to No Placebo. Memory and attention tasks assessed cognitive enhancement. Nocebo effects were assessed by symptom checklist.

RESULTS

More symptoms were reported in the Deceptive Placebo condition (M = 2.65; SD = 2.27) than Open Placebo (M = 1.92; SD = 2.24; Mann-Whitney U = 1,654, z = 2.30, p = .022) or No Placebo (M = 1.68; SD = 1.75, Mann-Whitney U = 1,640, z = 2.74, p = .006). Participants were more likely to attribute symptoms to Modafinil side-effects if they believed pharmaceuticals to be generally harmful (incidence rate ratio [IRR] = 1.70, p = .019), had higher perceived sensitivity to medicines (IRR = 1.68, p = .011), stronger concerns about Modafinil (IRR = 2.10, p < .001), and higher negative affectivity (IRR = 2.37, p < .001).

CONCLUSIONS

Beliefs about medication are potentially modifiable predictors of the nocebo effect. These findings provide insight into side-effect reports to placebo and, potentially, active treatment.

Explaining placebo effects in an online survey study: Does 'Pavlov' ring a bell?

OBJECTIVES

Despite the increasing knowledge about placebo effects and their beneficial impact on treatment outcomes, strategies that explicitly employ these mechanisms remain scarce. To benefit from placebo effects, it is important to gain better understanding in how individuals want to be informed about placebo effects (for example about the underlying mechanisms that steer placebo effects). The main aim of this study was to investigate placebo information strategies in a general population sample by assessing current placebo knowledge, preferences for different placebo explanations (built around well-known mechanisms involved in placebo effects), and attitudes and acceptability towards the use of placebo effects in treatment.

DESIGN

Online survey.

SETTING

Leiden, The Netherlands.

PARTICIPANTS

444 participants (377 completers), aged 16-78 years.

MAIN OUTCOME MEASURES

Current placebo knowledge, placebo explanation preferences, and placebo attitudes and acceptability.

RESULTS

Participants scored high on current placebo knowledge (correct answers: M = 81.15%, SD = 12.75). Comparisons of 8 different placebo explanations revealed that participants preferred explanations based on brain mechanisms and positive expectations more than all other explanations (F(7, 368) = 3.618, p = .001). Furthermore, attitudes and acceptability for placebos in treatment varied for the type of the condition (i.e. more acceptant for psychological complaints) and participants indicated that physicians do not always have to be honest while making use of placebo effects for therapeutic benefit.

CONCLUSION

Our results brought forth new evidence in placebo information strategies, and indicated that explanations based on brain mechanisms and positive expectations were most preferred. These results can be insightful to construct placebo information strategies for both clinical context and research practices.

Patients' beliefs and behaviours are associated with perceptions of safety and concerns in a hypothetical biosimilar switch

Although patient acceptance is important for biosimilar adoption and reducing healthcare costs, many patients perceive biosimilars to be unsafe and have concerns about switching. Studies show that patients' characteristics influence negative perceptions toward generic drugs, but little research has explored biosimilar acceptance. This study examines which demographic and psychological characteristics are associated with patients' safety perceptions and concerns about switching to biosimilars. Ninety-six patients taking bio-originators for rheumatic conditions (65% for rheumatoid arthritis) completed the Brief Illness Perceptions Questionnaire, Beliefs about Medicines Questionnaire and Perceived Sensitivity to Medicines Scale. Demographic factors, information seeking, concerns about switching and safety perceptions were also assessed. Pearson's correlations and hierarchical linear regressions were conducted to explore whether patient characteristics are associated with perceptions of biosimilars. Negative safety perceptions were associated with being female, short-term bio-originator use, illness beliefs, seeking health information online, high perceived sensitivity to medicines and negative beliefs about medicines. Only being female (β = 0.24, P = 0.02) was independently associated. More concerns about switching were associated with being female, illness beliefs, high perceived sensitivity to medicines, information-seeking behaviours and preferring innovator drugs. Seeking health information online (β = 0.20, P = 0.04), preferring innovator drugs (β = 0.29, P = 0.004) and stronger emotional responses (β = 0.26, P = 0.01) were independently associated. Perceived bio-originator effectiveness was inversely associated with preferring biosimilars (r_s=  - 0.33, P < 0.001). Patients who have stronger emotional responses to their condition, are females, seek health information online and prefer innovator drugs that have more negative perceptions about biosimilars. Experiences with bio-originators influence attitudes towards switching.

It is not just the drugs that matter: the nocebo effect

The role of psychological mechanisms in the treatment process cannot be underestimated, the well-known placebo effect unquestionably being a factor in treatment. However, there is also a dark side to the impact of mental processes on health/illness as exemplified by the nocebo effect. This phenomenon includes the emergence or exacerbation of negative symptoms associated with the therapy, but arising as a result of the patient's expectations, rather than being an actual complication of treatment. The exact biological mechanisms of this process are not known, but cholecystokinergic and dopaminergic systems, changes in the HPA axis, and the endogenous secretion of opioids are thought to be involved. The nocebo effect can affect a significant proportion of people undergoing treatment, including cancer patients, leading in some cases to the cessation of potentially effective therapy, because of adverse effects that are not actually part of the biological effect of treatment. In extreme cases, as a result of suggestions and expectations, a paradoxical effect, biologically opposite to the mechanism of the action of the drug, may occur. In addition, the nocebo effect may significantly interfere with the results of clinical trials, being the cause of a significant proportion of complications reported. Knowledge of the phenomenon is thus necessary in order to facilitate its minimalization and thus improve the quality of life of patients and the effectiveness of treatment.

Decreasing the Burden of Side Effects Through Positive Message Framing: an Experimental Proof-of-Concept Study

PURPOSE

Informing patients about treatment side effects increases the occurrence and intensity of side effects. Since the obligatory informed consent procedure in drug treatments requires transparency and nocebo research suggests that the informed consent of a drug leads to an increased occurrence of the mentioned side effects, the aim of this proof of concept study was to determine the effect of two different framings of informed consent on the occurrence, intensity, and perceived threat of side effects.

METHODS

Healthy male participants (n = 80) were randomized to one of two framing groups. The positive framing group was informed that the common side effect dizziness was a sign that the drug had started to work, while the neutral framing group was told that dizziness is an unpleasant but well-known side effect. Side effects were measured after the administration of metoprolol, an antihypertensive agent. Post hoc moderator analyses investigated the effect of pre-existing negative beliefs about the general harm of medication on the framing manipulation.

RESULTS

Metoprolol-specific drug-attributed side effects were rated significantly less threatening in the positive framing group. The between-group effect size (Cohen's d) was small (d = 0.38, p = 0.049). Exploratory post hoc moderator analyses suggest that participants who believed that medication is a source of harmful effects benefited from positive framing, compared to neutral framing of drug-attributed side effects.

CONCLUSIONS

Positive framing was partially effective in decreasing specific side effect measures, particularly among participants with a tendency to believe that medicine is harmful. Informed consent procedures should therefore be personalized, focusing on patients with negative treatment beliefs.

‘You feel like you haven’t got any control’: A qualitative study of side effects from medicines

Objectives

An aging UK population and multi-morbidity means patients are receiving an increasing number of medicines. This can lead to greater risk of unintended side effects. The aim of this study was to increase understanding of how people identify and manage side effects from their medicines.

Design

A qualitative interview study with patients who had experienced side effects, recruited from community pharmacies.

Methods

This study examined patients’ experiences of side effects and the impact of these effects on their daily life. Fifteen participants were interviewed – 10 females and 5 males, with ages that ranged between 25 and 80 years, using different types and numbers of medicines.

Results

Thematic analysis revealed six themes: side effect experience, identification, adherence, information use, coping and body awareness. Participants described a wide range of physical and psychological symptoms which had both explicit and implicit impact on their lives. A system of identification based on constructed cognitive processes was common across participants. A variety of strategies were used by participants to cope with their side effects which included information seeking, social support seeking and non-adherent behaviours.

Conclusions

Psychological factors, such as medication beliefs, symptom interpretation and body awareness, contribute to cognitive and behavioural processes used to identify and manage side effects. These processes can have significant impacts on an individual’s decisions about adherence.

The relationship between pharmacy students' beliefs about medications and their academic achievement in a pharmacy practice counseling course

INTRODUCTION

Pharmacists' beliefs about medications have been identified as a potential factor in how patients are counseled. However, no studies have assessed this relationship.

METHODS

Third year pharmacy students were surveyed using previously validated questionnaires about medication beliefs, including the BMQ-General (General-Overuse and General-Harm subscales), Benefit, and Perceived Sensitivity to Medications (Sensitive Soma) scales; each is rated on a five-point Likert scale (higher scores represent stronger feelings). Belief profiles were created using two-step cluster analysis. Students also reported demographics and prior work in a pharmacy. Grades from simulated counseling sessions were collected via school records. Student t-test and multivariate linear regression were used to compare beliefs with grades.

RESULTS

Among the 66 responders (84.5% response rate), 54.5% were female, 80.3% white, and 77.3% non-Hispanic; 84.8% reported prior work in a pharmacy. Overall mean (SD) belief scores were General-Overuse 3.12 (0.76), General-Harm 1.83 (0.53), Benefit 3.99 (0.55), and Sensitive Soma 2.37 (0.82). Cluster analyses revealed two beliefs profiles: negative profile (more feelings of overuse, harm, and sensitivity to medications) and positive profile (less feelings of overuse, harm, and sensitivity to medications). Students with positive belief profiles were graded higher by faculty compared to students with negative belief profiles (90.0 vs. 87.2, p = 0.014). Findings remained in a multivariate regression controlling for gender and prior work in a pharmacy.

CONCLUSIONS

Findings from this study demonstrate the need for greater understanding about the relationship between pharmacists' beliefs about medications and patient counseling.

Supporting Adherence to Medicines for Long-Term Conditions

Abstract. Pharmaceutical prescriptions are core to the treatment of most chronic illnesses, yet only half are taken as prescribed. Despite the high costs of nonadherence to individuals and society, effective adherence-promoting interventions are elusive. This is partly due to the sheer complicity of the issue. There are numerous determinants of adherence, both internal to the patient (intrinsic) and external (extrinsic, e.g., environmental or health system-related factors). Also, the relative importance of these determinants varies between individuals and even within the same individual over time and across treatments, presenting a challenge for intervention design. One complication is that interventions can target several levels: (1) patient (e.g., enhancing motivation and/or ability to adhere), (2) patient-provider interactions (e.g., improving communication and the prescribing process), and (3) the healthcare system (e.g., providing the opportunity to access medication through regulatory approval and co-payment schemes). Here, we focus on level 1: the patient. Although environmental factors are important, the effect of an intervention designed to change them will depend on how they impact on the individual. We describe the Perceptions and Practicalities Approach (PAPA), a pragmatic framework positing that adherence/nonadherence is essentially a produce of individual motivation and ability. Adherence interventions, targeted at any level, will therefore be more effective if tailored to address the perceptions and practicalities underpinning individual motivation and ability. We discuss how PAPA can be operationalized, including the application of theoretical models of illness and treatment representation (Necessity-Concerns Framework and Leventhal’s Common-Sense Model) to address salient adherence-related perceptions.

Minimizing Drug Adverse Events by Informing About the Nocebo Effect-An Experimental Study

Relevance: Informing patients about potential adverse events as part of the informed consent may facilitate the development of nocebo-driven drug adverse events (nocebo side effects). Objective: To investigate whether informing about the nocebo effect using a short information sheet can reduce nocebo side effects. Methods: A total of N = 44 participants with weekly headaches for at least 6 months were recruited using the cover story of a clinical trial for a headache medicine. In reality, all participants took a placebo pill and were randomized to the nocebo information group or the standard leaflet group. Participants were instructed to read the bogus medication leaflet entailing side effects information shortly before pill intake. The nocebo group additionally received an explanation about the nocebo effect as part of the leaflet. Questionnaires were completed at baseline, 2 min, and 4 days after the pill intake. We conducted general linear models with bootstrap sampling. Baseline symptoms were included as a covariate. Results: Most participants (70.5%) reported nocebo side effects at 2 min. Participants who received the nocebo information (n = 24) reported less nocebo symptoms than the control group (n = 20) (estimated difference: 3.3, BCa 95% CI [1.14; 5.15], p = 0.01, Cohen's d = 0.59). Baseline symptoms, perceived sensitivity to medicine, and side effect expectations each moderated the group effect (estimated difference in slope: 0.47, BCa 95% CI [0.19; 0.73], p = 0.001, d = 0.75; 1.07 [0.27; 1.61], p = 0.006, d = 0.73; 1.57 [0.38; 2.76], p = 0.02, d = 0.58). No group differences were found at 4-day follow-up. After revealing the actual aim of the study, 86% of the participants evaluated the nocebo information to be helpful in general. Conclusions: Results provide the first evidence that informing about the nocebo effect can reduce nocebo side effects.

Introducing the 'Drucebo' effect in statin therapy: a systematic review of studies comparing reported rates of statin-associated muscle symptoms, under blinded and open-label conditions

BACKGROUND

The 'placebo effect' and 'nocebo effect' are phenomena whereby beneficial (placebo) or adverse (nocebo) effects result from the expectation that an inert substance will relieve or cause a particular symptom. These terms are often inappropriately applied to effects experienced on drug therapy. Quantifying the magnitude of placebo and nocebo effects in clinical trials is problematic because it requires a 'no treatment' arm. To overcome the difficulties associated with measuring the nocebo effect, and the fact that its definition refers to inert compounds, rather than drugs, we introduce the concept of 'drucebo' (a combination of DRUg and plaCEBO or noCEBO) to relate to beneficial or adverse effects of a drug, which result from expectation and are not pharmacologically caused by the drug. As an initial application of the concept, we have estimated the contribution of the drucebo effect to statin discontinuation and statin-induced muscle symptoms by performing a systematic review of randomized controlled trial of statin therapy.

METHODS

This preferred reporting items for systematic reviews and meta-analysis-compliant systematic review was prospectively registered in PROSPERO (CRD42017082700). We searched PubMed and Cochrane Central from inception until 3 January 2018 using a search strategy designed to detect studies including the concepts (Statins AND Placebo AND muscle pain). We included studies that allowed us to quantify the drucebo effect for adverse muscle symptoms of statins by (i) comparing reported rates of muscle symptoms in blinded and unblinded phases of randomized controlled trials and (ii) comparing rates of muscle symptoms at baseline and during blinded therapy in trials that included patients with objectively confirmed statin intolerance at baseline. Extraction was performed by two researchers with disagreements settled by a third reviewer.

RESULTS

Five studies allowed the estimation of the drucebo effect. All trials demonstrated an excess of side effects under open-label conditions. The contribution of the drucebo effect to statin-associated muscle pain ranged between 38% and 78%. The heterogeneity of study methods, outcomes, and reporting did not allow for quantitative synthesis (meta-analysis) of the results.

CONCLUSIONS

The drucebo effect may be useful in evaluating the safety and efficacy of medicines. Diagnosis of the drucebo effect in patients presenting with statin intolerance will allow restoration of life-prolonging lipid-lowering therapy. Our study was limited by heterogeneity of included studies and lack of access to individual patient data. Further studies are necessary to better understand risk factors for and clinical management of the drucebo effect.

The Power of Labeling in Nocebo Effects

Nocebo effects comprise two broad types: primary nocebo effects, in which overall treatment efficacy is reduced; and nocebo side effects, which result in the increased experience of unpleasant secondary side effects. An important factor in generating nocebo effects of both types is the patient's expectations of how well a treatment will work, and how likely it is to cause side effects. One source of negative expectations is the presence of generic-as opposed to brand name-labeling. A medicine's labeling is likely to be one of the first aspects of a treatment that is encountered by a patient, and perhaps the most common labeling information on pharmaceuticals is the labeling that identifies the drug as being made by the originator brand manufacturer, or as a generic copy. Although generic medicines are pharmaceutically equivalent to their brand name counterparts, generics are often viewed with distrust and perceived to be inferior to branded medicines. Negative perceptions of generic pharmaceuticals may contribute to reduced treatment efficacy via enhanced primary nocebo effects, and increased nocebo side effects. This chapter reviews evidence for the role of brand and generic labeling in treatment outcomes across a range of contexts-most often laboratory research assessing pain outcomes, as well as the influence of related factors including price, familiarity, and treatment switches. Although increasing evidence suggests that labeling of medicines can shape nocebo effects, interventions to improve perceptions of generics do not necessarily translate into more positive treatment outcomes.

Medicine-related beliefs predict attribution of symptoms to a sham medicine: A prospective study

OBJECTIVES

To investigate a range of possible predictors of nocebo responses to medicines.

DESIGN

Prospective cohort study.

METHODS

In total, 203 healthy adult volunteers completed measures concerning demographics, psychological factors, medicine-related beliefs, baseline symptoms, and symptom expectations before taking a sham pill, described as 'a well-known tablet available without prescription' that was known to be associated with several side effects. Associations between these measures and subsequent attribution of symptoms to the tablet were assessed using a hurdle model consisting of a joint logistic and truncated negative binomial regression.

RESULTS

Men had an increased odds of attributing symptoms to the tablet OR = 1.52, and older participants had decreased odds, OR = 0.97. Medicine-related beliefs were important, with modern health worries, belief that medicines cause harm and perceived sensitivity to medicines associated with increased odds of symptom attribution, OR = 1.02, 1.10, 1.09, respectively. Trust in medicines and pharmaceutical companies decreased the odds of symptom attribution, OR = 0.91, 0.88, respectively. The number of symptoms at baseline and the expected likelihood of symptoms were associated with an increased odds of attributing symptoms to the tablet, OR = 1.07, 1.06, respectively. Anxiety, previous symptom experience, symptom expectations, and modern health worries were also important in predicting the number of symptoms participants attributed to the tablet.

CONCLUSION

It is hard to predict who is at risk of developing nocebo responses to medicines from demographic or personality characteristics. Context-specific factors such as beliefs about and trust in medicines, current symptoms and symptom expectations are more useful as predictors. More work is needed to investigate this in a patient sample. Statement of contribution What is already known on this subject? Many patients report non-specific side effects to their medication which may arise through a nocebo effect. Whether some people are particularly predisposed to experience nocebo effects remains unclear. What does this study add? Demographic and personality characteristics are poor predictors of symptom attribution to a sham medicine. Instead, context-specific factors that concern people's beliefs surrounding medicines, their current symptoms, and symptom expectations are more useful as predictors of symptom attribution.

Public risk perception of non-prescription medicines and information disclosure during consultations: a suitable target for intervention?

OBJECTIVE

Optimisation of non-prescription medicine (NPM) supply from community pharmacies could reduce demand on other healthcare providers, including general practitioners and emergency department personnel. Outcomes can be maximised if patients disclose relevant information, for example concomitant medication, during pharmacy-based consultations. Strategies to promote information disclosure are needed. This study used the psychometric paradigm of risk to explore whether the public's risk perception of NPMs was associated with information disclosure.

METHODS

This national, cross-sectional population study used a random sample of 3000 adults (aged ≥ 18 years) from the Scottish Electoral register. Postal questionnaires collected data on risk perceptions, information disclosure and demographic information. Exploratory factor analysis was used to determine constructs to which the risk questions could be grouped. Factors were scored and the scores compared across demographics.

KEY FINDINGS

Just over half (57%) of the 927 respondents perceived NPMs to be associated with low general risk. For 19 of the 23 statements (83%), respondents indicated general agreement, that is low-risk perception of NPMs. Individuals with higher risk perception of NPMs were less likely to disclose information during consultations compared with respondents with lower risk perception.

CONCLUSION

There is general low public risk perception of NPMs. Individuals with higher risk perception are less likely to disclose information. Interventions that raise risk perception are unlikely to enhance the safe and effective supply of NPMs.

Patient-doctor relationship and adherence to capecitabine in outpatients of a German comprehensive cancer center

PURPOSE

The prescribing of oral chemotherapy agents has introduced the new challenge of ensuring patients' adherence to therapy. Aspects of a close patient-doctor relationship are reported to be correlated with adherence to oral anticancer drugs, but data on capecitabine are scarce.

PATIENTS AND METHODS

Sixty-four outpatients with a diagnosis of cancer and prescribed capecitabine were recruited from a German Comprehensive Cancer Center. We used the Patient-Doctor Relationship Questionnaire (PDRQ-9), the Medical Adherence Rating Scale (MARS), the Beliefs about Medicines Questionnaire (BMQ), and the Satisfaction with Information about Medicines Scale (SIMS) to assess patients' perceptions and behavior. Medical data were extracted from the charts.

RESULTS

Non-adherence was reported by 20% of the 64 participants. The perceived quality of the patient-doctor relationship was high in general, but it did not emerge as a predictor of adherence in our survey (odds ratio [OR]=0.915, P=0.162, 95% CI=0.808-1.036). However, beliefs about medicine (OR=1.268, P<0.002; 95% CI=1.090-1.475) as well as satisfaction with information about medicine (OR=1.252, P<0.040, 95% CI=1.010-1.551) were predictors of adherence and the quality of the patient-doctor relationship was correlated with both variables (r=0.373, P=0.002 for SIMS sum score; r=0.263, P=0.036 for BMQ necessity/concern difference). Overall, adherence to capecitabine was high with a conviction that the therapy is necessary. However, concerns were expressed regarding the long-term effect of capecitabine use. Patients have unmet information needs regarding interactions of capecitabine with other medicines and the impairment of their intimate life.

CONCLUSIONS

In order to ensure adherence to capecitabine, our results seem to encourage the default use of modern and perhaps more impersonal means of information brokerage (eg, email, internet). However, the contents of some of patients' informational needs as well as the associations of patients' beliefs and satisfaction about the information received suggest a benefit from a trustful patient-doctor relationship.

Bad news: The influence of news coverage and Google searches on Gardasil adverse event reporting

BACKGROUND

Human papilloma virus vaccines are a safe and effective tool for reducing HPV infections that can cause cervical cancer. However, uptake of these vaccines has been suboptimal, with many people holding negative beliefs and misconceptions. Such beliefs have been linked with the experience of unpleasant side effects following medical treatment, and media coverage may heighten such concerns.

METHODS

The present study sought to assess the influence of news coverage (number of news articles per month) on adverse event reporting in response to Gardasil vaccination in New Zealand over a 7.5-year period, and whether the influence of news coverage was mediated by internet search activity (Google search volumes). Multiple linear regression analyses and simple mediation analyses were used, controlling for year and number of vaccinations delivered.

RESULTS

News coverage in the previous month, and Google search volumes in the same month, were significant predictors of adverse event reporting, after accounting for vaccination rates and year. Concurrent Google search volumes partially mediated the effect of prior news coverage.

CONCLUSION

The results suggest that some of the adverse events reported were not related to the vaccination itself, but to news coverage and internet search volumes, which may have contributed to public concerns about potentially unpleasant or harmful outcomes. These findings have implications for the importance of psychological and social factors in adverse event reporting, and the role of the news media in disseminating health information.

Neuropsychiatric adverse drug reactions in children initiated on montelukast in real-life practice

Although montelukast is generally well tolerated, postmarketing studies have reported serious neuropsychiatric adverse drug reactions (ADRs) leading to a United States Food and Drug Administration black box warning. The objective of this study was to determine the incidence of neuropsychiatric ADRs leading to discontinuation of montelukast in asthmatic children.We conducted a retrospective cohort study in children aged 1-17 years initiated on montelukast. In a nested cohort study, children initiated on montelukast as monotherapy or adjunct therapy to inhaled corticosteroids (ICS) were matched to those initiated on ICS monotherapy. A non-leading parental interview served to ascertain the occurrence of any ADRs with any asthma medication, and circumstances related to, and evolution of, the event.Out of the 106 participants who initiated montelukast, most were male (58%), Caucasian (62%) with a median (interquartile range) age of 5 (3-8) years. The incidence (95% CI) of drug cessation due to neuropsychiatric ADRs was 16 (10-26)%, mostly occurring within 2 weeks. Most frequent ADRs were irritability, aggressiveness and sleep disturbances. The relative risk of neuropsychiatric ADRs associated with montelukast versus ICS was 12 (2-90).In the real-life setting, asthmatic children initiated on montelukast experienced a notable risk of neuropsychiatric ADRs leading to drug cessation, that is significantly higher than that associated with ICS.

Participant-Reported Symptoms and Their Effect on Long-Term Adherence in the International Breast Cancer Intervention Study I (IBIS I)

Purpose To assess the role of participant-reported symptoms on long-term adherence to preventive therapy in the United Kingdom sample of the International Breast Cancer Intervention Study (IBIS-I). IBIS-I was a randomized controlled trial that investigated the effectiveness of tamoxifen in reducing the risk of breast cancer among women at increased risk of the disease. Participants and Methods Women were randomly assigned to tamoxifen versus placebo (20 mg/day; n = 4,279). After 456 exclusions, 3,823 women were included in this analysis. Adherence (< 4.5 years or ≥ 4.5 years) was calculated using data from six monthly clinical visits. Analyses were adjusted for age, Tyrer-Cuzick risk, smoking, use of hormone replacement therapy, menopausal status, baseline menopausal symptoms, and treatment. Results Overall, 69.7% of women were adherent for at least 4.5 years (tamoxifen: 65.2% v placebo: 74.0%; P < .001). Differences in adherence between treatment arms were observed from 12 months onward (all P < .01) and were largest at 54 months. Dropout rates were highest in the first 12 to 18 months and decreased thereafter. Women reporting nausea/vomiting were less likely to be adherent in both the tamoxifen (odds ratio [OR], 0.57; 95% CI, 0.37 to 0.86; P = .007) and placebo (OR, 0.58; 95% CI, 0.37 to 0.93; P = .023) arms. Headaches were associated with adherence only in the placebo arm (OR, 0.62; 95% CI, 0.42 to 0.91; P = .016), whereas gynecologic symptoms were significant only in the tamoxifen arm (OR, 0.77; 95% CI, 0.62 to 0.97; P = .024). Effect sizes for each symptom on adherence were not significantly different between the treatment groups ( P > .05). In both treatment arms, we observed significant trends for lower adherence with increasing severity for all symptoms ( P < .01) except headaches ( P = .054). Conclusion In the IBIS-I trial, experiencing predefined symptoms in the first 6 months reduced long-term adherence. Effects were similar between treatment arms, suggesting that women were attributing age-related symptoms to preventive therapy. Interventions were required to support symptom management.

No blank slates: Pre-existing schemas about pharmaceuticals predict memory for side effects

OBJECTIVES

Attribution of symptoms as medication side effects is informed by pre-existing beliefs about medicines and perceptions of personal sensitivity to their effects (pharmaceutical schemas). We tested whether (1) pharmaceutical schemas were associated with memory (recall/recognition) for side effect information (2) memory explained the attribution of a common unrelated symptom as a side effect.

DESIGN

In this analogue study participants saw the patient leaflet of a fictitious asthma drug listing eight side effects.

MAIN OUTCOME MEASURES

We measured recall and recognition memory for side effects and used a vignette to test whether participants attributed an unlisted common symptom (headache) as a side effect.

RESULTS

Participants who perceived pharmaceuticals as more harmful in general recalled fewer side effects correctly (r_{Correct Recall} = -.273), were less able to differentiate between listed and unlisted side effects (r_{Recognition Sensitivity} = -.256) and were more likely to attribute the unlisted headache symptom as a side effect (r_{side effect attribution} = .381, ps < .01). The effect of harm beliefs on side effect attribution was partially mediated by correct recall of side effects.

CONCLUSION

Pharmaceutical schemas are associated with memory for side effect information. Memory may explain part of the association between pharmaceutical schemas and the attribution of unrelated symptoms as side effects.

The Human Dimension: Putting the Person into Personalised Medicine

Technological advances enabling us to personalise medical interventions at the biological level must be matched by parallel advances in how we support the informed choices essential to patient and public participation. We cannot take participation for granted. To be truly personalised, medicine must take account of the perceptions and capabilities that shape participation. To do this, we need a better understanding of how people perceive personalised medicine and how they judge its value and risks. To realise the promise of 4P medicine we need to personalise at the psychosocial as well as biological dimension, putting the person into personalised medicine.

Patient-provider communication and hormonal therapy side effects in breast cancer survivors

Side effects from hormonal therapy (HT) for breast cancer treatment occur frequently and are associated with worse quality of life and HT non-adherence. Whether improved patient-physician communication is associated with patients' reporting of side effects is unknown. We undertook this study to assess factors associated with women's reports of HT side effects. Between December 2012 and April 2013, we conducted a cross-sectional survey of breast cancer patients undergoing HT in an urban medical center. Descriptive statistics, univariate analyses, and multivariate analyses were used to evaluate associations. Of the 100 participants, 67% reported having HT side effects. However, when prompted, an additional 9% reported experiencing specific HT-related symptoms. Despite very high communication scores, one-third of participants reported they had not discussed side effects with providers. Multivariate analysis showed that after controlling for age, education, race, and medication beliefs, women who had difficulty asking providers for more information were more likely to report side effects (odds ratio 8.27, 95% confidence interval 1.01-69.88). Although HT side effects often occur and are bothersome, patient-provider discussions about side effects remain suboptimal. Providers should actively ask patients about medication side effects so that they can be addressed to improve quality of life and potentially, medication adherence.