Adherence to Psychotropic Medications and Associated Factors in Primary Health Care

Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review

BACKGROUND

Mental illness and medication safety are key priorities for healthcare systems around the world. Despite most patients with mental illness being treated exclusively in primary care, our understanding of medication safety challenges in this setting is fragmented.

METHOD

Six electronic databases were searched between January 2000-January 2023. Google Scholar and reference lists of relevant/included studies were also screened for studies. Included studies reported data on epidemiology, aetiology, or interventions related to medication safety for patients with mental illness in primary care. Medication safety challenges were defined using the drug-related problems (DRPs) categorisation.

RESULTS

Seventy-nine studies were included with 77 (97.5%) reporting on epidemiology, 25 (31.6%) on aetiology, and 18 (22.8%) evaluated an intervention. Studies most commonly (33/79, 41.8%) originated from the United States of America (USA) with the most investigated DRP being non-adherence (62/79, 78.5%). General practice was the most common study setting (31/79, 39.2%) and patients with depression were a common focus (48/79, 60.8%). Aetiological data was presented as either causal (15/25, 60.0%) or as risk factors (10/25, 40.0%). Prescriber-related risk factors/causes were reported in 8/25 (32.0%) studies and patient-related risk factors/causes in 23/25 (92.0%) studies. Interventions to improve adherence rates (11/18, 61.1%) were the most evaluated. Specialist pharmacists provided the majority of interventions (10/18, 55.6%) with eight of these studies involving a medication review/monitoring service. All 18 interventions reported positive improvements on some medication safety outcomes but 6/18 reported little difference between groups for certain medication safety measures.

CONCLUSION

Patients with mental illness are at risk of a variety of DRPs in primary care. However, to date, available research exploring DRPs has focused attention on non-adherence and potential prescribing safety issues in older patients with dementia. Our findings highlight the need for further research on the causes of preventable medication incidents and targeted interventions to improve medication safety for patients with mental illness in primary care.

Antidepressant Adherence Among Hispanics: Patients in an Integrated Health Care Model

Purpose

We report on antidepressant (AD) adherence among Hispanics seeking mental health services in a community primary care clinic in Texas as an ancillary outcome from a National Institutes of Health-funded study that collected data on Hispanic AD adherence over a period of two years (February 2016-February 2018). Adherence to AD medications was measured throughout the year-long trial and compared across various demographic characteristics. Since Hispanic individuals often experience stigma and cultural barriers related to AD treatment, we sought to understand what factors may increase the likelihood of non-adherence in this population.

Patients and Methods

This study focused on 69 patients who were prescribed AD medications while receiving treatment through an integrated health care model. Adherence was measured with the Patient Adherence Questionnaire, a validated 2-item questionnaire that asks patients about their medication use (missed medications or dosage changes) over the past week. We looked at patient adherence at two key time points (4-weeks and 13-weeks) and utilized logistic regression to identify factors that may increase or decrease the likelihood of adherence in Hispanic patients at a community primary care clinic.

Results

Non-adherence to AD medication was 49.3% at 4-weeks and 57% at 13-weeks post-treatment initiation. Logistic regression analyses revealed that age was the only significant predictor of AD non-adherence. As age increased, the likelihood of adherence increased by 12.2% at 13-weeks post-treatment initiation and by 11.1% at 4-weeks post-treatment initiation.

Conclusion

The likelihood of Hispanic patients to adhere to AD therapy increased with the age of the patient. Since primary care is the most likely place to be prescribed an AD for Hispanic patients, further research to better understand adherence is essential. Integrated health care interventions designed to help identify, reduce, or eliminate barriers to adherence and improve cultural understanding may help address issues of non-adherence in primary care settings.

Patient-Level Medication Regimen Complexity in an Adolescent and Adult Population with Autism Spectrum Disorders

BACKGROUND

Adults with autism spectrum disorder (ASD) frequently experience polypharmacy. However, there is limited understanding of how to quantify medication complexity in this vulnerable population.

OBJECTIVES

This study examined medication administration difficulty using the Medication Regimen Complexity Index (MRCI) tool in adolescents and adults with ASD. The outcomes compared the mean total MRCI score with the medication count, described MRCI contributions for over-the-counter medication (OTC), and compared MRCI scores by patient characteristics.

METHODS

This was a retrospective chart review of patients aged 7-45 years (mean = 20.1) enrolled in a primary care ASD transitions program. Each patient's listed medications were counted and then scored using the validated MRCI tool.

RESULTS

For the 142 patients studied, mean total MRCI was 14.6 ± 14.6 (range 0-89) and mean medication count was 6.3 ± 5.4 (range 0-38). For patients on 0-4 medications (66 of 142; 46.5%), the mean MRCI was 5.5 ± 4.2, 5-9 medications (50 of 142; 35.2%) the mean MRCI was 15.2 ± 6.8, and 10-38 medications (26 of 142; 18.3%) the mean MRCI was 36.5 ± 18.9 (p<0.001). Sixty percent (85 of 142) reported OTC use, which contributed 26.6% to the mean total MRCI. Reported benzodiazepine (mean MRCI 25.8 ± 17.2), antiepileptic (mean MRCI 23.7 ± 16.9), antipsychotic (mean MRCI 19.7 ± 15.9), or antidepressant (mean MRCI 17.0 ± 14.8) use received higher MRCI scores compared to nonuse (p<0.001 for all except antidepressants [p=0.004]). Total MRCI did not differ significantly by age group, sex, or attention-deficit-hyperactivity disorder (ADHD) medication use (stimulant or nonstimulant).

CONCLUSIONS

Medication regimen complexity in adolescents and adults with ASD was increased significantly for individuals taking ≥ 5 medications. Central nervous system agent use, other than ADHD therapy, identified patients with higher regimen complexity. The related clinical effects of these findings warrant further investigation.

Pharmaceutical interventions in mental health: A review of the literature to support evidence-informed policymaking

BACKGROUND

Pharmaceutical interventions may have an impact on different treatment aspects, such as therapy adherence, reducing the number of different medications in use and lowering treatment costs.

OBJECTIVE

Identify pharmaceutical interventions in the mental health field and their possible application in Brazilian public mental health services, considering the evidence-based model to establish implementation options.

METHODS

A structured search of the literature was performed in the Pubmed (Medline), Cochrane, PsycINFO and Lilacs databases to identify the main pharmaceutical intervention studies conducted in the mental health area. The articles selected were evaluated according to the quality of the evidence. The current laws and public database were researched to collect information on services and procedures provided by the Brazilian units, known as CAPS, and the number the pharmacists allocated to them. The proposal to synthesize the results of pharmaceutical interventions in Brazil was based on SUPPORT methodology items to prepare evidence-based policies.

RESULTS

A total of 1442 studies were identified, 18 of which were included. Several interventions are reported in the literature, educational interventions being frequently cited. However, there is a need for further studies with more methodological rigor. The number of pharmacists working in the CAPS is insufficient to cover all the services, since only 26.5% of CAPS employ pharmacists, who work an average of 29 (±11.1) hours a week. Three options were formulated to implement interventions in the Brazilian context that consider including pharmacists on the basic team of CAPS professionals and educational interventions through pharmacist training.

CONCLUSIONS

The present study could support the establishment of health policies, based on a synthesis of the evidence, contextualization of the current situation, given the absence of local evidence, and a discussion of the options available to implement pharmaceutical interventions in the Brazilian health system. Organizational changes in CAPS are needed to broaden pharmacist participation on the multidisciplinary team.