Factors associated with patients' knowledge of and attitudes towards treatment with lithium

Practices, knowledge, and attitudes about lithium treatment: Results of online surveys completed by clinicians and lithium-treated patients

BACKGROUND

Lithium remains the gold-standard medication for acute and prophylactic treatment of bipolar disorder. Understanding clinicians' practices and patients' experiences, knowledge and attitudes about lithium may improve its clinical use.

METHODS

Online anonymous surveys collected information about clinician's practices and level of confidence in managing lithium and patients' experiences with lithium treatment and information received about benefits and side effects. Knowledge and attitudes regarding lithium were assessed with the Lithium Knowledge Test (LKT) and the Lithium Attitudes Questionnaire (LAQ).

RESULTS

Among 201 clinicians, 64.2% endorsed often treating patients with lithium and reported high levels of confidence in assessing and managing lithium. Practices concerning clinical indications, drug titration, and serum levels were guideline-concordant, but compliance with monitoring recommendations was less frequent. Practitioners were interested in receiving more education about lithium. The patients' survey recruited 219 participants with 70.3% being current lithium users. Most patients (68%) found lithium helpful and 71% reported experiencing any kind of side effect. Most responders did not receive information about side effects or other benefits of lithium. Patients with higher scores on the LKT were more likely to have positive attitudes about lithium.

LIMITATIONS

Cross-sectional design with predominantly English-speaking participants from Brazil and North America.

CONCLUSIONS

There is a discrepancy between guidelines, clinician confidence and knowledge of lithium use and practice. A deeper understanding of how to monitor, prevent and manage long-term side effects and which patients are most likely to benefit from lithium may narrow the gap between knowledge and use.

Self-Reported Low Lithium Adherence Among Chinese Patients with Bipolar Disorder in Shenzhen: A Cross-Sectional Study

BACKGROUND

Lithium has been widely used to treat bipolar disorder (BD), although its adherence is rarely reported in China. This study aimed to explore the rate of lithium adherence and its associated factors in patients with BD, which has rarely been reported in China.

METHODS

We conducted a cross-sectional study among patients in Shenzhen Mental Health Center (Shenzhen Kangning Hospital), who were aged 12 years or above, were diagnosed with BD based on the International Classification of Diseases, tenth edition (ICD-10), and had been on lithium for at least 1 month. We collected information on sociodemographic and clinical characteristics and on knowledge about and attitudes toward lithium. We also investigated patients' concerns while taking lithium and where they can and wish to obtain information on lithium.

RESULTS

Of the 244 enrolled patients and 221 patients aged 18 years or older, 52% and 50% disclosed low adherence to lithium, respectively. Factors associated with poor lithium adherence were a younger age (odds ratio (OR): 0.962, 95% confidence interval (CI): 0.933-0.992), female sex (OR: 2.171, 95% CI: 1.146-4.112), and no hospitalization history (OR: 0.389, 95% CI: 0.217-0.689) for the full sample, and more years of education (OR: 4.086, 95% CI: 1.397-11.946) and fewer hospitalizations (OR: 0.615, 95% CI: 0.467-0.809) for patients aged 18 years or older. Less knowledge of periodic tests conducted during lithium treatment played a critical role in low lithium adherence (regression analysis of the full sample: OR: 0.642, 95% CI: 0.532-0.775, regression analysis of subgroups: OR: 0.609, 95% CI: 0.500-0.742). The treatment duration was a major concern among patients on lithium, and patients preferred obtaining lithium-associated information through health services and WeChat.

CONCLUSION

The rate of lithium adherence was low in this study. Psychoeducation to increase lithium compliance should mainly focus on patients who are young and provide thorough background information on lithium. Health services should actively provide lithium-associated information. A greater need for medication information based on WeChat was observed, implying its potential role in adherence-related psychoeducation.

Assessment of lithium-related knowledge and attitudes among patients with bipolar disorder on long-term lithium maintenance treatment

BACKGROUND

Gaps in lithium-related knowledge among bipolar disorder (BD) patients on lithium prophylaxis may pose safety concerns and could adversely influence attitudes to lithium.

OBJECTIVE

To assess the lithium-related knowledge and attitudes among patients with BD.

MATERIALS AND METHODS

This was a cross-sectional, observational study assessing euthymic, adult outpatients with BD on lithium prophylaxis (≥1 year) using a semi-structured pro forma, lithium questionnaire for knowledge, lithium attitude questionnaire (LAQ), and medication adherence rating scale (MARS).

RESULTS

Descriptive analysis revealed several deficits in knowledge, including lack of critical safety information or need for periodic blood tests. Lower knowledge group had significantly more negative attitudes. Favorable attitude toward lithium (lower LAQ score) was significantly associated with the number of psychiatric follow-ups in the last year and MARS score.

CONCLUSION

There were critical deficits in lithium-related knowledge among the patients. Lower lithium knowledge was associated with negative lithium attitudes. Educative interventions should be delivered periodically to regular lithium users.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Self-reported medication adherence and its correlates in a lithium-maintained cohort with bipolar disorder at a tertiary care centre in India

BACKGROUND

Lithium remains a cornerstone of prophylaxis in bipolar disorder (BD), but adherence continues to be a major clinical challenge and merits a closer attention. There is scant literature available in Indian as well as Asian context.

METHODS

This study was conducted at Department of Psychiatry, AIIMS, New Delhi with an aim to assess the self-reported medication adherence and its correlates among a naturalistic, lithium-maintained cohort (n = 76) with bipolar disorder. Subjects were included if they were on lithium therapy ≥1 year, met DSM-5 diagnosis of bipolar disorder and were in clinical remission (≥1 month). Besides sociodemographic and clinical performa, participants were assessed on medication adherence rating scale (MARS), lithium questionnaire for knowledge and lithium attitude questionnaire (LAQ).

RESULTS

Mean age was 35.7 ± 10.6 years (males: 59.2%); median duration of illness and lithium therapy was 84 months and 24.5 months, respectively. Mean MARS score was 6.95 ± 2.81. Regression analysis (with MARS total as dependent variable) found LAQ score to be the single most significant predictor variable (β=-0.681, p < 0.0001), explaining over 75% of the total variance. In regression model with MARS factor-1 score as dependent variable, the 'LAQ score' (β=-0.601, p < 0.0001) and 'being accompanied by family during psychiatric visits (always/mostly) in the past year' (β = 0.193, p = 0.010) emerged as significant predictor variables.

CONCLUSION

Adherence in lithium-maintained treatment-seeking cohort of patients with BD remains far from ideal as observed in this naturalistic setting. Lithium-related attitudes and being accompanied by family during psychiatric visits were found to be significant predictors for adherence.

Demographic correlates of medication knowledge in Hong Kong early psychosis patients

AIM

Patient knowledge of prescribed medications is important for accurate medication consumption. Not many studies have identified the demographic correlates of medication knowledge in psychiatric patients, and fewer have performed so for non-Western societies, which may present different results owing to distinct cultural factors. Our objective was to identify the demographic correlates of medication knowledge in early psychosis patients from Hong Kong.

METHODS

A short questionnaire comprising questions on six components of medication knowledge was administered to 105 consecutive early psychosis patients from an outpatient clinic in Hong Kong. A suite of patient demographics was assembled from clinicians' records.

RESULTS

Poor medication knowledge was characterized by patients of older age (>30 years), low education level (≤Form 3), overall negative family relationships (as compared with overall positive ones) and shorter treatment duration (≤4 years). Shorter treatment duration most consistently predicted poor medication knowledge, displaying significant (P < 0.05) associations with four out of six knowledge components. Patients (54.3%) did not know the English names of their medication.

CONCLUSIONS

Specific groups of early psychosis patients are at risk of having poor medication knowledge; these individuals should be identified to receive regular health education. Contrary to findings from non-psychosis groups, short treatment duration was unequivocally associated with poorer medication knowledge in patients with early psychosis. Local replacements for English medication names should be considered in non-English speaking societies, especially in areas of mental health treatment.

Outcomes of patient education practices to optimize the safe use of lithium: A literature review

INTRODUCTION

Lithium is commonly used to treat various psychiatric disorders and is particularly effective in the maintenance phase of bipolar disorder. Unfortunately, this drug has a narrow therapeutic index and, if not monitored regularly, can result in toxicity. Therefore, for lithium to be prescribed safely, clinicians must ensure that patients are well educated on lithium toxicity, its prevention, and symptom recognition. This article summarizes studies that investigated lithium education strategies to help promote the safe use of lithium.

METHODS

Four electronic databases were searched using key terms and subject headings. Reference lists of relevant papers were also reviewed. The search was limited to literature published in English, without year limits. Eligible studies examined lithium patient education and the impact on patients' knowledge of safe lithium use.

RESULTS

Of a total of 517 citations that were retrieved from the electronic database search, 12 were selected for inclusion in this review. Most of the studies included assessed the effect of lithium education on various aspects of patients' knowledge, including but not limited to, lithium toxicity. Of the studies assessing the correlation between lithium knowledge and lithium levels, most demonstrated a positive correlation between lithium knowledge and lithium levels that were more stable and within the higher end of the recommended therapeutic range.

CONCLUSIONS

Studies evaluating lithium patient education and its effect on improving the safe use of lithium are limited. Nevertheless, this literature review highlights that lithium patient education is critical to promote its safe use.

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.

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.

Correlates of attitudes towards mood stabilizers in individuals with bipolar disorder

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A survey of patients' knowledge about lithium therapy in the elderly

OBJECTIVE

Lithium is commonly used in the treatment of various psychiatric disorders. It has a narrow therapeutic range and a mortality rate of 9% in patients intoxicated during maintenance therapy. Therefore, for lithium to be prescribed safely, clinicians must ensure that patients are aware of features of lithium toxicity. We aim to identify patients' knowledge of lithium in the elderly population and associated factors that may influence this knowledge.

METHOD

The Lithium Knowledge Test (LKT) is a brief questionnaire that was developed as a means of identifying patients' practical and pharmacologic knowledge, which is important if therapy is to be safe and effective. The survey was conducted in the outpatient service of the Department of Old Age Psychiatry attached to a university teaching hospital in an urban area in Ireland between January 2011 and July 2011. A total of 33 patients participated in the survey, and the LKT questionnaires were completed by all participants. The LKT scores are obtained by adding up the responses to the questions, while the LKT hazard scores are obtained by adding together the responses to the questions on symptoms of toxicity. The result was analyzed using SPSS version 20 (SPSS Inc, Chicago, Illinois), and the relationships between LKT scores and LKT hazard scores as well as other variables were examined using Pearson's correlation coefficient.

RESULTS

The mean LKT score of our sample population was 4.45, suggestive of poor knowledge of lithium, and the mean LKT hazard score was 5.85, highly suggestive of potentially hazardous lack of knowledge. There was a significant negative correlation between the LKT score and hazard score (r = -0.65, P < .01 [1-tailed]).

CONCLUSIONS

The survey results highlight the need for patients to be given comprehensive information about lithium prior to commencement of treatment and a refresher educational program during lithium therapy.

Predictors of adherence to psychopharmacological and psychosocial treatment in bipolar I or II disorders - an 18-month prospective study

BACKGROUND

Poor treatment adherence among patients with bipolar disorder (BD) is a common clinical problem. However, whether adherence is mostly determined by patient characteristics or attitudes, type of treatment or treatment side-effects remains poorly known.

METHODS

The Jorvi Bipolar Study (JoBS) is a naturalistic prospective 18-month study representing psychiatric in- and outpatients with DSM-IV BD I and II in three Finnish cities. During the 18-month follow-up we investigated the continuity of, attitudes towards and adherence to various types of psychopharmacological and psychosocial treatments among 168 psychiatric in- and outpatients with BD I or II.

RESULTS

One-quarter of the patients using mood stabilizers or atypical antipsychotics discontinued medication during at least one treatment phase of the follow-up autonomously, mostly during depression. When pharmacotherapy continued, adherence was compromised in one-third. Rates of non-adherence to mood stabilizers or antipsychotics did not differ, but the predictors did. One-quarter of the patients receiving psychosocial treatments were non-adherent to them.

LIMITATIONS

Serum concentrations were not estimated.

CONCLUSIONS

More than one-half of BD patients either discontinue pharmacotherapy or use it irregularly. Autonomous discontinuation takes place mostly in depression. Although rates of non-adherence do not necessarily differ between mood-stabilizing medications, the predictors for nonadherence do. Moreover, adherence to one medication does not guarantee adherence to another, nor does adherence at one time-point ensure later adherence. Attitudes towards treatments affect adherence to medications as well as to psychosocial treatments and should be repeatedly monitored. Non-adherence to psychosocial treatment should be given more attention.

Poor response to treatment: beyond medication

In psychiatry, one of the main factors contributing to poor response to pharmacological treatment is adherence. Noncompliance with maintenance treatments for chronic illnesses such as schizophrenia and affective disorders can exceed 50%, Poor adherence can be due to drug-related factors (tolerance, complexity of prescription, side effects, or cost), patient-related variables (illness symptoms, comorbidity, insight capacity, belief system, or sociocultural environment), and physician-related factors (communication or psychoeducational style). Psychosocial treatments must be used in conjunction with medication during the maintenance phase to improve adherence to treatment and to achieve - through the management of psychological variables - better social, work, and family functioning. This article reviews the concepts of adherence and noncompliance, and their impact on maintenance treatments, as well as the effect of dealing with psychosocial factors in psychiatric treatment.

Psychoeducation for patients with bipolar disorder receiving lithium: short and long term impact on locus of control and knowledge about lithium

BACKGROUND

Psychoeducation is now considered as part of the integrated treatment for bipolar disorder. But the psychological changes involved in it have been poorly studied.

METHOD

We compared the locus of control (LOC, a key variable for health-related behaviours as well as for education practices), the knowledge about lithium [Lithium Knowledge Questionnaire (LKQ)] and attitude about lithium [Attitude towards Lithium Questionnaire (ALQ)] before and after a brief hospital based psychoeducational programme for euthymic patients with bipolar disorder (ICD-10 criteria) receiving lithium prophylaxis. The occurrence of hospitalisations was recorded during the two years before and after the patients underwent psychoeducation. All patients were reassessed after 24 months.

RESULTS

50 consecutive participants at a psychoeducational programme were evaluated. The LKQ but not the ALQ scores increased significantly after the programme. The external "powerful others" component of the LOC significantly increased after psychoeducation. The observed changes were maintained after 24 months. The patients' level of satisfaction was excellent and sustained. There was only a trend for a decrease in the rate of hospitalisations.

LIMITATIONS

The knowledge about lithium was assessed with an experimental instrument. Patients followed in a university department may not be representative of bipolar patients at large.

CONCLUSIONS

Psychoeducation enduringly increases the knowledge about lithium and induces long term changes in the locus of control that may reflect a shift in illness representations. The LOC may be an important target of psychoeducation for euthymic patients with bipolar disorder.

Enhancing medication adherence in patients with bipolar disorder

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Correlation between drug treatment adherence and lithium treatment attitudes and knowledge by bipolar patients

BACKGROUND

Non-adherence should always be investigated when there is a failure in bipolar treatments, since it is known that reported non-adherence rates in bipolar disorder treatment for long-term prophylactic pharmacotherapy range from 18% to 52%, with a median prevalence of 44.7%. Several factors are related to the poor adherence and reduction of medication efficiency, such as the different types of bipolar disorder, the presence of side effects, medication interactions, level of patient's knowledge about the disorder and their attitude towards treatment, complexity of medical regimens and the doctor-patient relationship.

METHODS

Bipolar disorder outpatients under lithium treatment from the Hospital de Clínicas and Materno Infantil Presidente Vargas of Porto Alegre were recruited. All the patients had bipolar disorder and gave informed consent to participate in a clinical interview (106), answered the Lithium Attitudes Questionnaire (LAQ), Lithium Knowledge Test (LKT), Medication Adherence Rating Scale (MARS) and had plasma and red blood cells lithium measurements to assess their medication adherence and the factors that influenced it.

RESULTS

85.6% of bipolar disorder were adherent to lithium treatment showing plasma lithium between 0.6 and 1.2 mmol/L. There was an inverted correlation between the total LAQ score with plasma and red blood cells, a positive correlation between LKT and MARS with plasma and red blood cell lithium.

CONCLUSION

These results confirmed that knowledge level is directly correlated to treatment adherence and patients' attitudes, lower adherence, general opposition to prophylaxis, fear of side effects, denial of therapeutic effectiveness and illness severity.

Adherence behaviour with psychotropic medication is a form of self-medication

Adherence with psychotropic medication is at least at poor as adherence with medication for physical health problems. There has been an assumption this was due to loss of insight resulting from psychiatric disorders themselves. Consequently, interventions have focussed on treating the underlying psychiatric disorder and generating psychological strategies to promote awareness. Recent surveys of patient preferences for information and involvement in health care decisions highlight that most individuals want to participate in the process of medical care. Patients often have strong pre-existing beliefs about different therapeutic options. This is supported by the self-determination theory which distinguishes between autonomous behaviour and behaviours that are influenced by external forces. When considering the patient perspective in medication adherence, it is useful to consider the self-medication hypothesis. This can equally be applied to prescribed and non-prescribed drugs. The self-medication hypothesis states that patients decide to start, adjust or stop prescribed medication according to perceived health needs. Such decisions are often conducted intentionally and rationally, given the information available to the patient and their understanding of their condition. In this narrative review, the evidence for and against intentionality in psychotropic adherence behaviour is examined. Studies of compliance and related predictors are examined in depression, schizophrenia and bipolar affective disorder. Results suggest that although concordance depends on patient, illness and clinician factors, patient choice is usually the final common pathway. Illness severity and insight is important in some cases but can act in concert with cognitive factors. Individuals appear to prefer to take medication "as required" (symptomatically) rather than prophylactically. Significant influences upon self-medication habits are prior health beliefs, medication attitudes, adverse effects and adequacy of communication from the health care professional. The self-medication hypothesis applied to prescribed psychotropic medication should assist rather than heed clinicians in improving adherence by taking a patient centred approach and where possible promoting patient autonomy.

Adaptation and validation of the Portuguese version of the Lithium Knowledge Test (LKT) of bipolar patients treated with lithium: cross-over study

OBJECTIVE

Adherence problems are a common feature among bipolar patients. A recent study showed that lithium knowledge was the main difference between adherent and non adherents bipolar patients. The Lithium Knowledge Test (LKT), a brief questionnaire, was developed as a means of identifying aspects of patients' practical and pharmacological knowledge which are important if therapy is to be safe and effective. The original English version is validated in psychiatric population, but a validated Portuguese one is not yet available.

METHODS

One hundred six patients selected were diagnosed with bipolar disorder (I or II) according to DSM-IV criteria and had to be on lithium treatment for at least one month. The LKT was administered on only one occasion. We analysed the internal consistency, concurrent validity, sensitivity and specificity of the LKT for the detection of the knowledge about lithium treatment of bipolar patients.

RESULTS

The internal consistency, evaluated by Cronbach's alpha was 0.596. The mean of total score LKT by bipolar patients was 9.0 (SD: 0.75) for men and 8.74 (SD: 0.44) for women. Concurrent validity based on plasma lithium concentration showed a significant correlation between the total LKT score and plasma lithium (r = 0.232; p = 0.020). The sensitivity was 84% and specificity was 81%.

CONCLUSION

LKT is a rapid, reliable instrument which appears to be as effective as a lengthier standard interview with a lithium clinic doctor, and which has a high level of acceptability to lithium patients. We found that the psychometric assessment of the Portuguese version of LKT showed good internal consistency, sensitivity and specificity.

Validation of the Portuguese version of the Lithium Attitudes Questionnaire (LAQ) in bipolar patients treated with lithium: cross-over study

BACKGROUND

Poor adherence to lithium is very common in bipolar patients and it is a frequent cause of recurrence during prophylactic treatment. Several reports suggest that attitudes of bipolar patients interfere with adherence to lithium. The Lithium Attitudes Questionnaire (LAQ) is a brief questionnaire developed as a means of identifying and grouping the problems patients commonly have with taking lithium regularly. The original version is validated in patients, but a validated version in Portuguese is not yet available.

METHODS

One-hundred six patients with bipolar disorder (DSM-IV criteria) criteria under lithium treatment for at least one month were assessed using LAQ. LAQ is a brief questionnaire administered under interview conditions, which includes 19 items rating attitudes towards prophylactic lithium treatment. We analysed the internal consistency, concurrent validity, sensitivity and specificity of the Portuguese version of LAQ.

RESULTS

The internal consistency, evaluated by Cronbach's alpha was 0.78. The mean total LAQ score was 4.1. Concurrent validity was confirmed by a negative correlation between plasma lithium concentration and total LAQ score (r = -0,198; p = 0.048). We analysed the scale's discriminative capacity revealing a sensitivity of 69% and a specificity of 71% in the identification of negative attitudes of bipolar patients.

CONCLUSION

The psychometric assessment of the Portuguese version of LAQ showed good internal consistency, sensitivity and specificity. The results were similar to the original version in relation to attitudes of bipolar patients towards lithium therapy.

Invocation of coercion context in compliance communication -- power dynamics in psychiatric care

This article draws on observations from ethnographic fieldwork to develop a theoretical understanding of the power dynamics in psychiatric care. The aim is to analyze how psychiatric clinicians solve compliance problems by invoking "coercion context". It is suggested that clinicians take a rather instrumental approach to laws regulating coercive intervention. Clinicians may invoke a coercion context even with voluntary patients. For example, they may use wordings that connote coercion, or they may make use of how treatment wards are set up to accommodate involuntary patients, thus stalling voluntary patients who cannot exit through locked doors. A coercion context can also be invoked to solve mundane practical problems, e.g. when clinicians talk about "coerced showers". The management of information and maintaining a suitable "awareness context" with regards to coercion is an essential feature in clinical attempts to achieve compliance from patients. In conclusion, the notion of coercion context helps explain the confusing findings from previous research about patients' apparent misconceptions of their formal legal status. Furthermore, it is argued that research that rely on decontextualised, objectifications of "coercion" risk to miss the meaning coercion is assigned in everyday clinical practice.

A collaborative approach to the treatment alliance in bipolar disorder

OBJECTIVES

The treatment alliance is the arena in which psychopharmacological and other therapeutic interventions occur. The nature and quality of the treatment alliance may affect adherence to treatment and the realization of the benefits of effective pharmacological treatment in clinical practice. It is an area that has attracted little systematic study, despite the available evidence suggesting that it plays a measurable role in clinical outcomes.

METHODS

A literature search was undertaken using Medline, Ovid, Psychinfo and Science Direct from 1975 to 2004. The following key words were used: bipolar disorder, patient adherence, non-adherence to medication, compliance, doctor-patient relationship, doctor-patient communication, treatment alliance, therapeutic alliance, chronic illness management, collaborative care, self-management, health beliefs, self-efficacy, self-determination, autonomy support, motivational interviewing.

RESULTS

Psychosocial interventions have demonstrated positive effects on adherence problems. Studies of the impact of the treatment alliance on outcomes in mental illness highlight the possibilities of fruitful research in this area in bipolar disorder. Different theoretical models of changing health related behaviour may inform approaches to the treatment alliance.

CONCLUSIONS

Results suggest the usefulness of a collaborative approach to the treatment alliance. Attention needs to be given to developing intervention models that target modifiable risk factors for non-adherence and address patient, clinician and illness related variables to enhance medication adherence in the treatment alliance. Refinement of these models through controlled evaluation in real world settings may lead to integration in health care delivery systems.