Enhancing medication adherence: clinician outcomes from the Medication Alliance training program

A customized adherence enhancement program for adolescents and young adults with suboptimal adherence and bipolar disorder: Trial design and methodological report

BACKGROUND

The onset of bipolar disorder (BD) is common during late adolescence and young adulthood (AYA). Suboptimal medication adherence is a critical yet modifiable risk factor for negative outcomes among AYAs with BD.

METHODS

This research used an iterative process (e.g., focus groups, advisory board, cognitive interviews) to modify an existing adherence intervention to address suboptimal adherence in AYAs with BD. The modified version of Customized Adherence Enhancement for Adolescents and Young Adults (CAE-AYA) will be compared to an Enhanced Treatment as Usual condition (ETAU) in 40 AYAs intervention using a 6-month prospective, randomized controlled trial (RCT) in a high-risk group of 16-21 year old AYAs with BD with demonstrated non-adherence to their prescribed BD medications.

CONCLUSIONS

This report describes the methodology and design of the ImprovinG adhereNce In adolescenTs with bipolar disordEr (IGNITE) study. If successful, the CAE-AYA approach has the potential to advance care for vulnerable youth with BD.

Cognitive behavioural therapy for eating disorders: how do clinician characteristics impact on treatment fidelity?

BACKGROUND

Clinicians routinely report not practising evidence-based treatments with eating disorders. There has been limited research investigating the impact of adaptable clinician characteristics such as self-efficacy and therapeutic optimism in this area. This study evaluated if there is a relationship between clinician therapeutic optimism, self-efficacy and the provision of evidence-based practice in the treatment of bulimia nervosa and binge eating disorder.

METHOD

A survey developed for this study was administered to 100 psychologists who were recruited online via a range of organisations affiliated with psychology and/or eating disorders. The survey measured demographic factors, eating disorder treatment knowledge, treatment fidelity, the use of individual treatment components and a range of clinician characteristics including self-efficacy and therapeutic optimism.

RESULTS

Results demonstrated that clinician self-efficacy was positively associated with and predicted treatment fidelity. Therapeutic optimism had significant low correlations with treatment fidelity but did not predict treatment fidelity.

CONCLUSION

These findings would suggest that strengthening clinician self-efficacy is useful in improving evidence-based practice in the treatment of binge eating disorder and bulimia nervosa and may also have implications in the training of clinicians. The study also demonstrated that the use of a range of knowledge translation strategies are valuable in enhancing clinician adherence to evidence-based practice. Further research with direct measures of treatment fidelity is needed to clarify these findings.

The relevance of professionals' attachment style, expectations and job attitudes for therapeutic relationships with young people who experience psychosis

BACKGROUND

Therapeutic relationships are a central component of community treatment for psychosis and thought to influence clinical and social outcomes, yet there is limited research regarding the potential influence of professional characteristics on positive therapeutic relationships in community care. It was hypothesised that professionals' relating style and attitudes toward their work might be important, and thus this exploratory study modelled associations between these characteristics and therapeutic relationships developed in community psychosis treatment.

METHODS

Dyads of professionals and young patients with psychosis rated their therapeutic relationships with each other. Professionals also completed measures of attachment style, therapeutic optimism, outcome expectancy, and job attitudes regarding working with psychosis.

RESULTS

Professionals' anxious attachment predicted less positive professional therapeutic relationship ratings. In exploratory directed path analysis, data also supported indirect effects, whereby anxious professional attachment predicts less positive therapeutic relationships through reduced professional therapeutic optimism and less positive job attitudes.

CONCLUSIONS

Professional anxious attachment style is directly associated with the therapeutic relationship in psychosis, and indirectly associated through therapeutic optimism and job attitudes. Thus, intervening in professional characteristics could offer an opportunity to limit the impact of insecure attachment on therapeutic relationships in psychosis.

Interrater reliability of the Observer Rating of Medication Taking scale in an inpatient mental health facility

Non-adherence to medication remains a major barrier to recovery from mental illnesses. Identification of those patients likely to experience adherence difficulties is best undertaken during inpatient treatment, prior to discharge into the community. More objective assessments of adherence behaviours might assist staff to more effectively target support to those patients most in need. This study investigated the interrater reliability of an inpatient behavioural observation scale of patient engagement with medication: the Observer Rating of Medication Taking (ORMT) scale. Eight mental health nurses working in a psychiatric hospital inpatient setting were trained in the use of the ORMT using video-based vignettes. Working in pairs, staff then independently rated adherence behaviours of 13 inpatients in a rehabilitation unit (total of 160 ratings) over a 1-week period. Concurrently, two expert raters also undertook independent ratings of patient medication-taking behaviour using the ORMT. Interrater reliability was assessed across both staff and expert raters. The results indicated that the ORMT has satisfactory interrater reliability, and can be appropriately used in an inpatient setting. The observational location of raters on the ward influenced the range of medication-taking behaviours observed, and thus the extent of concordance between raters. Further research to determine if the ORMT predicts adherence in the community is warranted.

Effect of mental health nurses' beliefs and knowledge of medication on their use of strategies to improve medication adherence

Despite the proven efficiency of medication for mental illness, research indicates low patient adherence to medication. Nonetheless, only few studies have directly examined the relationship between nurse beliefs and knowledge, and their use of strategies to improve patient adherence to psychiatric medication. Therefore, the aim of the present study was to clarify nurses' views, beliefs about, and knowledge of psychiatric medication affect their inclination to implement various strategies to improve patient adherence. One hundred nurses working at an Israeli psychiatric hospital participated in the study. Self-completed questionnaires were distributed. The research findings showed that nurses' levels of knowledge of psychiatric medication were moderate, but their beliefs of taking psychiatric medication were positive. The findings also showed that the higher the nurses' age and seniority, as well as their positive beliefs about taking medication, the higher their probability of implementing strategies to improve patient adherence to medication. Additionally, there was a positive correlation between positive beliefs about the nursing staff on taking medication and the staff's utilization of strategies to improve patient adherence to medication. The current study shows that nurses' traits and beliefs affect their use of strategies promoting mental health patient adherence to medication and the enhancement of these strategies.

Health care providers' perspectives of medication adherence in the treatment of depression: a qualitative study

PURPOSE

Non-adherence to antidepressant medications is a significant barrier to the successful treatment of depression. The purpose of this study was to explore the perspectives of health care providers on antidepressant medication non-adherence in clinical practice.

METHODS

Individual semi-structured interviews were conducted with a purposive sample of 31 health care providers from a range of disciplines and settings in the state of New South Wales, Australia. Interviews focused on medication adherence issues in depression and participants' strategies in addressing them. Interviews were audio recorded, transcribed verbatim and thematically content analyzed using a constant comparison approach.

RESULTS

Participants acknowledged medication non-adherence to be a complex problem in depression, and attributed this problem to patient, medication and environmental-specific issues. Five approaches in addressing non-adherence were reported: patient education, building partnerships with patients, pharmacological management, developing behavioural skills and building supportive networks. Challenges to the management of non-adherence were lack of time and skills, assessment of medication adherence, transition period immediately post-discharge and conflicts in views between providers.

CONCLUSION

Participants were able to identify issues and strategies in addressing antidepressant non-adherence; however, barriers were also identified that could impact on providers' ability to address this issue effectively. More research is needed to develop effective multidisciplinary strategies that take into account providers' perspectives in improving adherence to antidepressant medications.

Can physicians accurately predict which patients will lose weight, improve nutrition and increase physical activity?

BACKGROUND

Physician counselling may help patients increase physical activity, improve nutrition and lose weight. However, physicians have low outcome expectations that patients will change. The aims are to describe the accuracy of physicians' outcome expectations about whether patients will follow weight loss, nutrition and physical activity recommendations. The relationships between physician outcome expectations and patient motivation and confidence also are assessed.

METHODS

This was an observational study that audio recorded encounters between 40 primary care physicians and 461 of their overweight or obese patients. We surveyed physicians to assess outcome expectations that patients will lose weight, improve nutrition and increase physical activity after counselling. We assessed actual patient change in behaviours from baseline to 3 months after the encounter and changes in motivation and confidence from baseline to immediately post-encounter.

RESULTS

Right after the visit, ~55% of the time physicians were optimistic that their individual patients would improve. Physicians were not very accurate about which patients actually would improve weight, nutrition and physical activity. More patients had higher confidence to lose weight when physicians thought that patients would be likely to follow their weight loss recommendations.

CONCLUSIONS

Physicians are moderately optimistic that patients will follow their weight loss, nutrition and physical activity recommendations. Patients might perceive physicians' confidence in them and thus feel more confident themselves. Physicians, however, are not very accurate in predicting which patients will or will not change behaviours. Their optimism, although helpful for patient confidence, might make physicians less receptive to learning effective counselling techniques.

Development of an instrument to measure attitudes of physical therapy providers working with people with dementia

BACKGROUND AND PURPOSE

This study investigated the factor structure of an instrument to measure attitudes and beliefs of how physical therapist (PT) practitioners perceive working with people with a dementia disorder.

METHODS

A survey was mailed to every skilled nursing facility in Indiana (n = 495) for completion by a PT or physical therapist assistant. The survey was developed and included whether the severity of Alzheimer's disease (AD) impacts the attitudes of physical therapy practitioners.

RESULTS

Of the 12 attitudinal questions, 11 were significant (P < .001) concerning how the severity of a diagnosis of AD (early, middle, and late) impacts attitudes of people in physical therapy practice. Principal component analysis identified 3 factors with Eigen values of 3.3 or higher accounting for 43% of the cumulative variance. These factors include professional competence, resources, and conscientiousness.

CONCLUSION

This brief instrument could serve as an assessment tool to determine whether PT practitioners exhibit therapeutic nihilism when working with people with a dementia disorder.

Comprehension and companionship in the emergency department as predictors of treatment adherence

OBJECTIVE

Lack of adherence to recommended treatment poses major clinical and economic challenges for psychiatry, and requires further examination. In this pilot study, we aimed to prospectively investigate the association between the level of understanding of psychiatric emergency department (ED) discharge recommendations and the presence of a companion with short-term treatment adherence.

METHOD

Sixty subjects were evaluated twice: upon ED discharge and a month later. Instruments included a structured questionnaire based on the MacArthur Competence Assessment Tool for Treatment, Mini Mental State Examination, and corroboration of data with the computerized hospital medical file. In order to control for the possibility that evaluation of the understanding of recommendations might positively influence adherence, the 60 subjects were randomly assigned into 50 who were interviewed with the full survey tool and 10 who were not asked questions about their understanding of treatment and/or follow-up recommendations.

RESULTS

Understanding of discharge recommendations and the presence of a companion enhanced adherence.

CONCLUSIONS

This preliminary study suggests that ensuring patients' understanding of treatment recommendations and encouraging the company of patients are achievable, practical strategies that may improve adherence and thereby promote better outcomes.

Enhancing patient adherence: outcomes of medication alliance training on therapeutic alliance, insight, adherence, and psychopathology with mental health patients

The results of interventions to enhance patient adherence to medication have been inconsistent. This research investigated the utility of an enhanced adherence training programme to ascertain its effectiveness and the possible mechanisms of that effect. Forty-six clinicians were trained in 'medication alliance', and data were collected from 51 patients matched to the clinician. Data on clinician changes in skills, knowledge, and attitudes, in relation to enhancing patient adherence and patient changes in adherence, insight, and psychopathology were collected at baseline and at 6 and 12 months. The quality of the therapeutic relationship between the clinician and the patient was also assessed. The results indicated significant improvements in both clinician and patient measures, the majority of which were maintained over time. The quality of the therapeutic relationship was also enhanced. A hypothesized explanatory model accounting for the data was supported. It was concluded that clinician training to support improved patient adherence should include strategies that also enhance the therapeutic alliance.

Training inpatient mental health staff how to enhance patient engagement with medications: Medication Alliance training and dissemination outcomes in a large US mental health hospital

RATIONALE, AIMS AND OBJECTIVES

The Medication Alliance training programme has previously been shown to be effective in enhancing clinician knowledge, attitudes and skills in regard to non-adherent individuals in a community-based psychiatric setting. The current study attempts to replicate these findings in an inpatient setting and assess the feasibility of dissemination using a train-the-trainer model.

METHOD

One hundred and thirteen staff from four wards at an inpatient psychiatric facility attended Medication Alliance training workshops over 3 days. Two wards comprised an expert trained group (n = 67); and the remaining two wards made up a novice trained group (n = 46). The novice trained group attended training 6 months after the expert group, and were trained by selected trainees from the expert group. Participants completed a package of questionnaires both before and after their training to determine if Medication Alliance resulted in any changes in knowledge, attitudes and skills.

RESULTS

Paired t-tests showed significant improvements across both groups for knowledge, attitudes and one skill domain following training in Medication Alliance. There were no differences at baseline between groups and analysis of post-test scores yielded no significant difference between the groups in terms of training effect for knowledge, attitudes or skills.

CONCLUSIONS

Medication Alliance can be successfully implemented in an inpatient setting, enhancing knowledge, attitudes and at least some skill domains of staff in dealing with non-adherent patients. The equivalence of results between the expert and novice trained training groups suggests that Medication Alliance may be more broadly disseminated using a cost-effective train-the-trainer model.

Implementation of the Strengths Model at an area mental health service

OBJECTIVE

The objectives of this paper are to provide an overview of recovery-focused models of care and discuss the implementation of the Strengths Model at St. Vincent's Mental Health Melbourne (SVMH), Victoria, Australia.

CONCLUSIONS

The implementation of the Strengths Model at SVMH is discussed with particular emphasis on the process of implementation, service implications, practical challenges and dilemmas that have arisen, and proposed evaluation. Recovery-focused care is feasible and can enhance current practice of mental health services.

Preliminary reliability of an observer rating scale for assessing medication adherence on psychiatric wards

OBJECTIVES

Medication non-adherence is a major contributor to poor outcomes following discharge from psychiatric hospitals. It is therefore imperative that staff are able to accurately assess the extent to which patients have engaged with treatment. This study presents data on a new observer rating instrument of patient medication adherence.

METHODS

Staff participating in a medication adherence training programme ('Medication Alliance') were given a brief overview of the Observer Rating of Medication Taking (ORMT) scale. Participants then watched six video vignettes of patient adherence behaviour and provided a rating on their scale for each vignette. Participant ratings were then compared with 'expert' ratings.

RESULTS

Percentage agreement between 'experts' and participants ranged from a low of 68% through to 98% agreement. Only one vignette was rated significantly differently [Mdiff = 0.33, t(49) = 2.08, P = 0.007], with 32% of people falling outside the expert rating range (all of those ratings being higher). This difference was attributed to between group differences, [F(2,47) = 3.49, P < 0.05] and post hoc assessment suggested that the differences between expert and trainee ratings for the vignette may be explained by trainee characteristics, as distinct from inherent characteristics of the rating scale.

CONCLUSION

The ORMT can help mental health professionals identify particular non-adherent behaviours thus facilitating identification and treatment of likely non-adherence before discharge. The scale appears to be accessible to a variety of professions with a range of experience and requires minimum training in order to be used reliably.

Mental health clinicians' beliefs about medicines, attitudes, and expectations of improved medication adherence in patients

Nonadherence to antipsychotic medications remains a major factor in poor clinical outcomes. This study sought to identify clinician beliefs about patients who do not adhere to treatment, the clinicians' own beliefs about medicines, and the impact of beliefs on efforts to enhance patient adherence. In total, 292 clinicians responded to an anonymous questionnaire that included questions about their beliefs and their efforts to enhance adherence. Results indicated that clinicians' beliefs about their own adequacy to enhance adherence significantly predicted actual efforts to enhance adherence. Both pessimism about outcomes and empathy for the patient predicted outcome expectancy. It was concluded that enhancing clinicians' beliefs about working with nonadherent patients is a potentially important ingredient in efforts to improve patient adherence.

Partial compliance with antipsychotic medication is common in patients with schizophrenia

OBJECTIVE

Partial compliance with antipsychotic medication increases relapse and rehospitalization rates in patients with schizophrenia. The aim of the present study was to assess the frequency of and factors contributing to partial compliance.

METHOD

During a 10 day period in June 2004 psychiatrists working in hospitals or in private practices in Germany were asked to participate in a compliance survey. Physicians were requested to evaluate the compliance in 10 patients with schizophrenia using a questionnaire consisting of 10 questions. The frequency of unintentional and intentional partial compliance as well as patient-related contributing factors were assessed. Unintentional partial compliance was defined as the lack of drug intake on any day during the past month. Demographic data of participants were collected. Responses were analysed using descriptive statistics and generalized estimation equation models.

RESULTS

The psychiatrists (n=699) regarded 68% of the evaluated patients (n=5729) as unintentionally partially compliant within the last month. Sixty-nine per cent of the patients were considered intentionally partially compliant in the past. The most frequently assessed patient-related factors contributing to the partial compliance were lack of insight into the need for prophylactic medication (68%), lack of insight/denial of illness (66%/63%), feeling embarrassed at taking medication every day (62%), needing someone to remind them to take their medication (62%), cognitive problems (55%), and living conditions inappropriate for compliance (46%).

CONCLUSIONS

Partial compliance is a common problem in schizophrenia. Strategies to improve partial compliance derived from the contributing factors identified in the present study may include regular telephone reminders by case managers or families, adequate support in the patients' environment, use of dosette boxes, rationalizing drug regimens (e.g. once-daily dosage, monotherapy, depot medication), and psychoeducation.

Teaching evidence-based psychotherapies

Currently our field is actively involved in developing new ways to characterize and treat children and adolescents with psychiatric disorders and in evaluating the effects of our therapies. We also are beginning to examine the effectiveness of our teaching methods. This article presents evidence for, ideas about, and a philosophy to guide individuals who are privileged to train child psychiatrists in psychotherapies. Specifically, it discusses the issues of the evidence base for diagnosis and for nonspecific and specific active elements of child psychotherapy. Evidence for methods of training is presented. The article addressed the need for supervising psychiatrists to keep abreast of developments in teaching methods so that we can best train competent, curious, and compassionate child psychiatrists.

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.