Medication Adherence Among Adolescents with Bipolar Disorder

Adherence Rates and Barriers to Second-Generation Antipsychotic Medication Use in Youth with Bipolar Spectrum Disorders Who Have Overweight/Obesity

Objective: Youth with bipolar spectrum disorders (BSD) are frequently prescribed second-generation antipsychotics (SGAs). Nonadherence to treatment often results in increased mood symptoms and diminished quality of life. We examined SGA adherence rates and adherence barriers among youth who have overweight/obesity and are diagnosed with BSD enrolled in a multisite pragmatic clinical trial. Methods: SGA adherence and adherence barriers at baseline via patient- and caregiver report was assessed. Adherence was defined as taking ≥70% of prescribed SGA doses in the past week. The weighted Kappa statistic was used to measure child-caregiver agreement about adherence rates, barriers, and caregiver assistance. Regression analyses were used to examine associations of caregiver assistance, age, sex, race, insurance status, dosing frequency, and number of concomitant medications with adherence. Barriers to adherence were analyzed separately for youth and their caregivers, using logistic regression to assess associations between informant-reported barriers and informant-reported adherence. Results: Participants included 1485 patients and/or caregivers. At baseline, 88.6% of patients self-reported as adherent; 92.0% of caregivers reported their child was adherent. Concordance between patients and caregivers was moderate (k = 0.42). Approximately, 50% of the sample reported no adherence barriers. Frequently endorsed barriers included forgetting, side effects, being embarrassed to take medications, and preferring to do something else. Concordance between informants regarding adherence barriers was weak (k = 0.05-0.36). Patients and caregivers who did not endorse adherence barriers reported higher adherence than those who endorsed barriers. Male sex and having once daily dosing of medications were associated with lower adherence. Discussion: One-week patient- and caregiver-reported adherence was high in this sample. Half of the sample reported adherence barriers. Most commonly endorsed barriers were forgetting, side effects, being embarrassed, and preferring to do something else. Caregivers and patients have unique perspectives regarding adherence barriers. Understanding and addressing treatment barriers in clinical practice may facilitate adherence.

A 6-month, prospective, randomized controlled trial of customized adherence enhancement versus a bipolar-specific educational control in poorly adherent adolescents and young adults living with bipolar disorder

OBJECTIVE

Few studies have addressed medication adherence in adolescents and young adults (AYAs) with bipolar disorder (BD). This 6-month prospective randomized-controlled trial (RCT) tested customized adherence enhancement for adolescents and young adults (CAE-AYA), a behavioral intervention for AYAs versus enhanced treatment as usual (ETAU).

METHODS

Inclusion criteria were AYAs age 13-21 with BD type I or II with suboptimal adherence defined as missing ≥20% of medications. Assessments were conducted at Screening, Baseline, and weeks 8, 12 and 24. Primary outcome was past 7 day self-reported Tablets Routine Questionnaire (TRQ) validated by electronic pillbox monitoring (SimpleMed). Symptom measures included the Hamilton Depression Rating Scale (HAM-D) and Young Mania Rating Scale (YMRS).

RESULTS

The mean sample age (N = 36) was 19.1 years (SD = 2.0); 66.7% (N = 24) female, BD Type I (81%). The mean missed medication on TRQ for the total sample was 35.4% (SD = 28.8) at screening and 30.4% (SD = 30.5) at baseline. Both CAE-AYA and ETAU improved on TRQ from screening to baseline. Baseline mean missed medication using SimpleMed was 51.6% (SD = 38.5). Baseline HAM-D and YMRS means were 7.1 (SD = 4.7) and 6.0 (SD = 7.3), respectively. Attrition rate at week 24 was 36%. Baseline to 24-week change on TRQ, adjusting for age, gender, educational level, living situation, family history, race, and ethnicity, showed improvement favoring CAE-AYA versus ETAU of 15%. SimpleMed interpretation was limited due to substantial missing data. There was a significant reduction in depression favoring CAE-AYA.

CONCLUSIONS

CAE-AYA may improve adherence in AYAs with BD, although conclusions need to be made cautiously given study limitations.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier: NCT04348604.

Development of the medical adherence scale in adolescents using psychotropic medication and evaluation of validity and reliability in Turkish population

PURPOSE

Although treatment non-adherence is relatively high among adolescents, there is a need for standardized measurement tools that measure adherence to treatment in adolescents. This study aimed to develop a new measurement tool to assess the adherence to treatment of adolescents with mental disorders who use psychotropic medication.

METHODS

The data of this methodologically designed study were collected between 01.04.2022 and 01.07.2023 in the Department of Child and Adolescent Psychiatry of a university hospital in the Aegean Region of Turkey. The Medication Adherence Reporting Scale and Adolescent Medical Adherence Scale draft form were used for data collection. The scale items were formed from the themes, sub-themes, and statements in the qualitative study that the researchers had conducted with adolescents with mental disorders and their parents, clinicians' experiences, and systematic reviews and meta-synthesis in the literature. The study sample consisted of 95 adolescents with mental disorders. Exploratory factor analysis was performed with Varimax rotation to determine the factorial construct validity of the scale. Internal consistency analyses were performed in reliability analyses, and Cronbach's alpha coefficient was used.

RESULTS

The mean age of the adolescents was 14.18 years (1.81); 50.5% were male, and 96.8% were attending school. When the mental disorder diagnoses were analyzed, 65.3% of the adolescents were being followed up with Attention Deficit and Hyperactivity Disorder diagnoses, and 58.8% were using stimulants. The 12-item form of the Adolescent Medical Adherence Scale was found to have a three-factor structure with item-total correlation values ranging between 0.26 and 0.66, and these factors were named functionality, responsibility in treatment, and medication adherence. Factor loadings ranged between 0.44 and 0.86, and the items explained 62.98% of the total variance. The internal consistency coefficients of the scale were between 0.69 and 0.83 for the subscales and 0.82 for the total scale.

CONCLUSION

Based on the analysis and results used in this study, the Adolescent Medical Adherence Scale is a valid and reliable new measurement tool.

PRACTICE IMPLICATIONS

This tool can be used in clinical settings to evaluate adolescents' treatment adherence and prognosis. Clinical studies conducted with adolescents can also determine adherence to treatment and affecting factors.

Utilization of Cultural Formulation Interview to understand the factors affecting treatment adherence and help-seeking in mood disorders: A qualitative study from Western India

Introduction

Treatment adherence rates among patients of affective disorders remain sub-par across the world. Sociocultural factors affecting the same remain poorly understood. The current study aimed to explore and conceptualize the same.

Methodology

The study utilized a qualitative grounded and phenomenological approach study design. The patients who fulfilled the Diagnostic and Statistical Manual of Mental Disorders - Fifth edition (DSM-5) criteria of unipolar depression or bipolar affective disorder, and were presently under our treatment for at least three months and currently in remission, aged 18-60 years, and were able to understand Hindi or English, scored less than 6 on the Medication Adherence Rating Scale were included. Furthermore, key caregivers were also included in the study. Using purposive sampling and data saturation, a total of 30 participants were recruited. In-depth interviews were conducted using the cultural formulation interview as given in DSM-5, which was used as the interview tool. Thematic analysis of data was performed using Atlas.ti version 8.4.3.

Results

A total of 14 themes (deductive and inductive) emerging from 171 codes were identified. Some of the important inductive themes included cultural and societal attitude toward illness and treatment-seeking, trust, experience, and expectations from available health care, faith healing-related practices and beliefs. The implicit themes such as cultural understanding of the problem and cultural factors affecting help-seeking, also showed prudent findings.

Conclusion

The study findings demonstrate the various features of the sociocultural milieu and identity of an individual and family that have an influence on treatment-seeking behavior.

Modification of an Intervention to Improve Adherence in Adolescents and Young Adults With Bipolar Disorder

Objective

Managing bipolar disorder (BD) is particularly challenging for adolescents and young adults (AYAs) ages 16 to 21. Few interventions exist that address self-management in AYAs with BD. Thus, this study aimed to modify the customized adherence enhancement behavioral intervention for AYAs through an iterative, patient-centered process.

Method

The Obesity-Related Behavioral Intervention Trials (ORBIT) model was used for intervention development. In phase 1a, adherence barriers and facilitators were identified to refine intervention content. Phase 1b occurred following curriculum modification to ensure that the modified intervention was relevant and usable by the target population. Data were collected via focus groups and interviews with AYAs with BD, parents, and providers. Transcripts were analyzed using directed content analysis.

Results

Phase 1a included focus groups/interviews with AYAs (n = 10), parents (n = 4), and providers (n = 9) who described the difficulties and successes in managing BD symptoms, improving adherence, and transitioning care from caregivers. Phase 1b included an advisory board composed of 8 phase 1a participants who provided feedback on modified session activities, module delivery, and curriculum. Phase 1b involved usability testing with new participants (n = 8), revealing the need for modifiable language based on developmental level, more engaging visual images, and confirmation that topics were salient to AYAs with BD.

Conclusion

Though sample sizes were small and not representative of the population of AYAs with BD, the ORBIT methodology informed the adaptation of the customized adherence enhancement intervention to improve adherence in AYAs with BD. Important next steps are to conduct a pilot randomized clinical trial of customized adherence enhancement for AYAs.

Examining Factors Associated With Medication Adherence in Youth With Bipolar Disorder

Objective

To assess medication adherence and factors associated with poor adherence in youth with bipolar disorder (BD) followed from adolescence through young adulthood.

Method

Participants with BD recruited through the Course and Outcome of Bipolar Youth (COBY) study were included in this study if they were prescribed psychotropic medications and had at least 3 follow-up assessments of medication adherence (N= 179, ages 12-36). Medication adherence had been evaluated for a median of 8 years using a questionnaire derived from the Coronary Artery Risk Development in Young Adults (CARDIA) study. For the longitudinal evaluation, adherence was measured as the percentage of follow-up assessments in which the participants did not endorse any of the nonadherence items included in the questionnaire. Concurrent and future predictors of poor adherence were assessed using both univariate and multivariate longitudinal analyses.

Results

Among the participants, 51% reported poor adherence in more than 50% of their follow-up assessments. Younger age, family conflicts, polypharmacy, lower functioning, greater severity of mood symptoms, and comorbid disorders were associated with poor adherence in the univariate analyses. In the multivariate analyses, comorbid ADHD was the single most influential factor associated with concurrent and future poor adherence in all age groups. Participants' most reported reasons for poor adherence were forgetfulness (56%), negative attitudes toward medication treatment (10.5%), and disturbed daily routine (7%).

Conclusions

Poor medication adherence is a significant problem in youth with BD with the most influential factor being the presence of comorbid ADHD. Thus, it is important to identify and appropriately treat comorbid ADHD to improve medication adherence and patients' prognosis. Providers should also recommend tools to enhance consistent medication intake and address patients' concerns and negative beliefs about their illness and treatment.

Parental Factors Associated with Child or Adolescent Medication Adherence: A Systematic Review

Medication adherence, especially among children and adolescents with psychiatric disorders, is often seen as a major treatment challenge. The purpose of this study is to systematically review studies addressing specific aspects of parental factors that are positively or negatively associated with medication adherence among children and adolescents with psychiatric disorders. A systematic literature search of English language publications, from inception through December 2021, was conducted from PubMed, Scopus, and MEDLINE databases. This review has complied with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. A total of 23 studies (77,188 participants) met inclusion criteria. Nonadherence rates ranged between 8% to 69%. Parents' socioeconomic background, family living status and functioning, parents' perception and attitude towards the importance of medication taking in treating psychiatric disorders, and parents' mental health status are significant parental characteristics associated with medication adherence in children and adolescents with psychiatric disorders. In conclusion, by identifying specific parental characteristics related to the medication adherence of children and adolescents with psychiatric disorders, targeted interventions on parents could be developed to guide parents in improving their child's medication adherence.

The effect of neuropsychiatric medication on pediatric nonalcoholic fatty liver disease

Obese and overweight children are at risk of developing nonalcoholic fatty liver disease (NAFLD), which can lead to steatohepatitis, cirrhosis, and liver transplantation. Neuropsychiatric conditions affect an increasing proportion of children and often require neuropsychiatric medications (NPMs) that are associated with weight gain and/or drug-induced liver injury. We sought to evaluate the role that the extended use of NPMs play in pediatric NAFLD. Medical chart review was conducted for 260 patients with NAFLD (NPM = 77, non-NPM = 183) seen in the Liver Care Center at Children's Mercy Hospital between 2000 and 2016. Outcome measures included body mass index (BMI) percentile, BMI z-score, aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, and gamma glutamyltransferase, and were collected at diagnosis, 6-18 month follow-up, and 18-36 months. Controlling for race and metformin, there was a significant increase over time in BMI z-score (p < 0.01) and total bilirubin (p = 0.03), with only initial decreases in ALT (p < 0.01) and AST (p < 0.01). Except for higher total bilirubin in the non-NPM group, no main effect of group or interaction effect was found. Similar patterns remained when subjects were analyzed by NPM drug class. Further study is needed to confirm these findings and to evaluate the effects of NPM dose and duration of exposure, by drug class, on pediatric NAFLD outcomes.

Perceptions and Experiences of Adolescents with Mental Disorders and Their Parents about Psychotropic Medications in Turkey: A Qualitative Study

This descriptive phenomenological study aimed to evaluate the perception and experiences of adolescents with mental disorders and their parents about the use of and adherence to psychotropic medications. A total of 12 semi-structured interviews with adolescents between the ages of 12 to 18 who were attending an outpatient psychiatric clinic for children and adolescents and 12 interviews with parents were conducted between October 2021 and January 2022 in Manisa, Turkey. Colaizzi’s phenomenological interpretation method was used for the analysis of the participants’ statements. Our study highlights the main positive effects of psychotropic medication and barriers to medication intake and adherence. Positive effects included symptom management and health improvement. Barriers varied from those directly linked to medication effects (e.g., negative side effects or lack of perceived effect) to personal barriers (e.g., forgetting to take medication or feelings of not being oneself due to medication intake) and societal barriers. In general, the barriers were reflected in concerns related to long-term consequences, such as medication dependence, and in concerns about diminished life prospects. Possible recommendations to improve the use of and adherence to psychotropic medication among adolescents include educating adolescents and parents not only about treatment options but also about mental disorders.

Efficacy, Tolerability, and Acceptance of Long-Lasting Antipsychotics in Children and Adolescents: A Systematic Review

Objectives: While long-lasting antipsychotics (LLA) were specifically developed to address the problem of adherence in patients with chronic psychiatric disorders, their role in pediatric populations is not clear. Methods: To document the efficacy, tolerance, and acceptance of LLAs in children and adolescents, a literature search was conducted using several databases for published studies (PubMed, PsycINFO) from January 1965 to December 2020. Twenty-two studies were identified (16 case reports/series, 3 open label studies, 2 controlled studies, and 1 retrospective analysis of national database). Results: Demographic features were widely heterogeneous across studies (total N = 480, 58% male, mean age = 15.0 ± 1.8). Case reports/series presented positive therapeutic outcomes in noncompliant youths with severe mental illness. Three open-label one-arm studies supported the clinical efficacy of risperidone long-acting injection in patients previously stabilized with oral risperidone. One study showed lower clinical symptoms and higher functioning at 12 months in youths treated for an acute psychotic episode with paliperidone palmitate compared to oral risperidone. The types and rates of side effects of LLA were comparable to those observed for oral antipsychotics. Two studies suggested better metabolic and neurological tolerance of LLA compared to an oral form. Preliminary evidence supported a satisfactory level of treatment satisfaction in patients treated with LLA and their families, while concerns were raised regarding practical administration in outpatient services. However, the average quality of the evidence based on the RoB2 tool was low. Conclusions: The level of evidence was low for the efficacy of LLA in pediatric populations and very low for the tolerance and acceptance. It concerned mostly the effect of risperidone long-acting injection in adolescents with psychotic disorders. Randomized maintenance clinical trials using noninferiority analysis would be more appropriate for further research.

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.

Psychosocial Treatments for Bipolar Disorder in Children and Adolescents

Evidence suggests that adjunctive psychosocial intervention for the treatment of pediatric bipolar spectrum disorders (BPSDs) is effective, feasible, and highly accepted as both an acute and maintenance treatment for youth with BPSD diagnoses as well as a preventive treatment for high-risk youth who are either asymptomatic or exhibit subsyndromal mood symptoms. Here, we provide a comprehensive review of all known evidence-based interventions, including detailed descriptions of treatment targets and core components, results of clinical trials, and updated research on mediators and moderators of treatment efficacy. Treatments are presented systematically according to level of empirical support (i.e., well established, probably efficacious, possibly efficacious, experimental, or questionable); upcoming and ongoing trials are included when possible. In line with a staging approach, preventive interventions are presented separately. Recommendations for best practices based on age, stage, and additional evidence-based child and family factors shown to affect treatment outcomes are provided. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Irritability, Anger, and Aggression in the Context of Pediatric Bipolar Disorder

Irritability, anger, and aggression, although not specific for pediatric bipolar disorder (BD), can be a common finding and an important source of distress and impairment in these patients. Over the past 2 decades the diagnostic significance of irritability in pediatric BD has been highly debated. Beyond the debate of its diagnostic significance, the clinical importance of irritability, anger, and aggression in youth with BD has been well established. In this review, the authors discuss evaluation and management strategies of irritability, anger, and aggression in youth with BD.

Medication Adherence in Pediatric Patients with Bipolar Disorder: A Systematic Review

Objectives: Pediatric bipolar disorder is a severe disabling condition affecting 1%-3% of youth worldwide. Both acute and maintenance treatment with medications are mainstays of treatment. It is well established in adult literature that adherence to medications improves outcomes and many adult studies have examined factors impacting adherence. This systematic review set out to identify the current state of research examining adherence to medications and characteristics influencing adherence in pediatric bipolar disorder. Methods: We performed a systematic literature review in the Medline, PsycINFO, CINAHL, EMBASE, Wiley Clinical Trials, and Cochrane databases. New research regarding characteristics and measurement of adherence to psychotropic medication for bipolar disorder (I, II, or not otherwise specified) in patients ≤18 years old were included for review. Exclusion criteria included no bipolar diagnosis, inclusion of patients >18 years old, no pharmacologic treatment, and lack of adherence measurements. Results: Initial search generated 439 articles after duplicate removal. One hundred thirty-three full-text articles were reviewed, 16 underwent additional review and 6 were selected for final inclusion. The majority of articles were excluded for patients >18 years old. Included articles were extremely heterogeneous for multiple measures, including methodology, determination of adherence, adherence rates, and characteristics influencing adherence. Of medications evaluated, 6/6 studies included mood stabilizers, 4/6 antidepressants, 3/6 antipsychotics, and 2/6 psychostimulants. Three out of six articles included patients <12 years old. Some significant factors affecting adherence included polypharmacy, comorbid psychiatric diagnoses, socioeconomic status, sex, family history and functioning, side effects, race, stability of bipolar diagnosis, and number of follow-up visits attended. Conclusions: Pediatric-specific information on medication adherence in bipolar disorder is very limited. Information on patient characteristics that may influence adherence rates is critical to target interventions to improve adherence. No articles reported on interventions to improve adherence. Given the different psychosocial situations of pediatric patients versus adults, it is likely that targets for improving adherence differ in pediatric patients.

Predicting Personalized Risk of Mood Recurrences in Youths and Young Adults With Bipolar Spectrum Disorder

OBJECTIVE

With each recurrence the prognosis of bipolar disorder (BD) worsens, indicating the need to identify the factors associated with increased recurrence risk. The course of BD is heterogenous and although risk factors for recurrence for the group as a whole have been reported in the literature, identification of risk factors for a specific individual are crucial for developing personalized treatments.

METHOD

A total of 363 recovered BD youths/young adults from the Course and Outcome of Bipolar Youth (COBY) study were included. Participants were evaluated on average every 7 months for a median of 12.5 years and interviewed with standard instruments. Risk factors of recurrence from the literature were used to build a risk calculator (RC) to predict recurrence risk at different time intervals.

RESULTS

Approximately 80% of participants had at least one syndromal recurrence and 60% had ≥2 recurrences, particularly depressions. The 6-month and 1-, 2-, 3-, and 5-year RC showed an accuracy between 72% and 82% for predicting any mood recurrences, and up to 80% for depression and 89% for hypo/mania (sensitivity/specificity both 0.74). The most influential recurrence risk factors were shorter recovery lengths, younger age at assessment, earlier mood onset, and more severe prior depression. Although important, other factors associated with recurrence risk, such as interepisodic subsyndromal mood symptoms and comorbidities, did not influence the RC score beyond factors noted above.

CONCLUSION

The RC provides a useful tool for predicting an individual's recurrence risk of depression and/or hypo/mania in BD youths and for developing personalized interventions and informing research. Replication studies are warranted.

The Importance of Second-Generation Antipsychotic-Related Weight Gain and Adherence Barriers in Youth with Bipolar Disorders: Patient, Parent, and Provider Perspectives

Objectives: The objective of this research was to understand physician, patient, and parent perspectives on barriers to second-generation antipsychotic (SGA) medication adherence in youth with bipolar spectrum disorders, and attitudes toward treatment of SGA-related weight gain. Methods: Patients diagnosed with bipolar disorder before age 18, parents of children diagnosed before 18, and clinicians with experience prescribing SGAs for these patients completed surveys regarding SGA-related side effects, adherence barriers, and acceptability of weight management strategies. Results: Patients (n = 225), parents (n = 128), and clinicians (n = 54) reported weight gain as the most concerning SGA-related side effect (45.6%, 38.9%, and 70.4%, respectively). Weight gain was also the top adherence barrier for patients (35.9%), but was ranked fourth (41.8%) by parents. Patients (61.5%) were more likely "definitely" willing to co-initiate another medication to manage weight gain upon SGA initiation than parents (20.1%) or clinicians (1.9%). Conversely, parents (54.9%) and clinicians (84.9%) were "definitely" willing to accept/prescribe a second medication aiming to reverse weight gain of ≥10 lbs., and patients (61.1%) were willing to add another medication to reverse any weight gain. Conclusion: SGA-related weight gain impairs medication adherence in young patients with bipolar disorder. Many young patients would start pharmacologic treatment to mitigate SGA-related weight gain at treatment initiation, parents and clinicians are more hesitant. This research informs patient-centered perspectives on SGA adherence barriers and strategies to minimize potential side effects, which may improve adherence in this vulnerable patient population.

A brief motivational intervention for enhancing medication adherence for adolescents with bipolar disorder: A pilot randomized trial

BACKGROUND

Youth with bipolar disorder (BP) exhibit poor medication adherence, contributing to affective recurrence. Brief Motivational Interventions (BMIs) improve adherence among adolescents with chronic conditions.

METHODS

In an open pilot series, we developed a 3-session BMI for BP adolescents targeting medication adherence and conducted a pilot randomized trial comparing Standard Care (SC) versus SC+BMI. Participants include 43 adolescents with BP prescribed psychotropic medications. We assessed medication adherence objectively via bluetooth-enabled electronic pillbox (MedTracker). A blinded evaluator assessed mood symptoms at intake, 3- and 6-months.

RESULTS

The BMI was well-received. Average objective medication adherence increased with time in SC+BMI, but decreased in SC-Alone (p < 0.0001). Adolescents' baseline self-rated expectation of improvement with treatment moderated the effect of treatment on improvement in adherence over time (p = 0.003). Across groups, poor adherence predicted increased likelihood of depression and hypo/mania symptoms in the subsequent two weeks; medication adherence mediated the effect of the BMI on the likelihood of depressive symptoms (p = 0.007).

LIMITATIONS

Electronic pillbox use (across groups) may enhance adherence, resulting in overestimates compared with naturalistic conditions. This pilot randomized trial may have been underpowered to detect some group differences.

CONCLUSIONS

A BMI offers promise as a disseminable adjunctive intervention for improving medication adherence for adolescents with BP. Future studies with larger samples can establish efficacy. NCT03203720.

Young people's experiences with mental health medication: A narrative review of the qualitative literature

Background: With the growing prevalence of mental illness in young people, healthcare professionals require an understanding of the social and psychological implications of medication use in this population.Aim: To characterize the qualitative literature regarding the perceptions and experiences of young people taking medication for mental illness.Methods: A narrative review of qualitative studies involving young people (13-24 years) taking any medication as treatment for a mental illness. The Medication Experience Model guided analysis of quotes related to medication use.Results: Of the 27 included studies, the majority involved participants with depression and utilized interviews. Young people reported a wide range of mental health medication experiences, both negative and positive, which could influence medication acceptance. Lack of autonomy and the influence of family members were challenges faced by this population.Conclusions: Young people reported that medications had affected them in various ways across multiple dimensions. Lack of involvement in decision-making and a loss of autonomy were of particular relevance to young people, issues which should also be of interest to healthcare professionals.

Patient-physician discordance in assessment of adherence to inhaled controller medication: a cross-sectional analysis of two cohorts

OBJECTIVE

We aimed to compare patient's and physician's ratings of inhaled medication adherence and to identify predictors of patient-physician discordance.

DESIGN

Baseline data from two prospective multicentre observational studies.

SETTING

29 allergy, pulmonology and paediatric secondary care outpatient clinics in Portugal.

PARTICIPANTS

395 patients (≥13 years old) with persistent asthma.

MEASURES

Data on demographics, patient-physician relationship, upper airway control, asthma control, asthma treatment, forced expiratory volume in one second (FEV₁) and healthcare use were collected. Patients and physicians independently assessed adherence to inhaled controller medication during the previous week using a 100 mm Visual Analogue Scale (VAS). Discordance was defined as classification in distinct VAS categories (low 0-50; medium 51-80; high 81-100) or as an absolute difference in VAS scores ≥10 mm. Correlation between patients' and physicians' VAS scores/categories was explored. A multinomial logistic regression identified the predictors of physician overestimation and underestimation.

RESULTS

High inhaler adherence was reported both by patients (median (percentile 25 to percentile 75) 85 (65-95) mm; 53% VAS>80) and by physicians (84 (68-95) mm; 53% VAS>80). Correlation between patient and physician VAS scores was moderate (r_s=0.580; p<0.001). Discordance occurred in 56% of cases: in 28% physicians overestimated adherence and in 27% underestimated. Low adherence as assessed by the physician (OR=27.35 (9.85 to 75.95)), FEV₁ ≥80% (OR=2.59 (1.08 to 6.20)) and a first appointment (OR=5.63 (1.24 to 25.56)) were predictors of underestimation. An uncontrolled asthma (OR=2.33 (1.25 to 4.34)), uncontrolled upper airway disease (OR=2.86 (1.35 to 6.04)) and prescription of short-acting beta-agonists alone (OR=3.05 (1.15 to 8.08)) were associated with overestimation. Medium adherence as assessed by the physician was significantly associated with higher risk of discordance, both for overestimation and underestimation of adherence (OR=14.50 (6.04 to 34.81); OR=2.21 (1.07 to 4.58)), while having a written action plan decreased the likelihood of discordance (OR=0.25 (0.12 to 0.52); OR=0.41 (0.22 to 0.78)) (R²=44%).

CONCLUSION

Although both patients and physicians report high inhaler adherence, discordance occurred in half of cases. Implementation of objective adherence measures and effective communication are needed to improve patient-physician agreement.

Medication Adherence Among Children and Adolescents with Severe Mental Illness: A Systematic Review and Meta-Analysis

OBJECTIVE

To perform a systematic review and meta-analysis of studies investigating predictors of medication adherence in children and adolescents with severe mental illness (SMI).

METHOD

A systematic literature search was conducted in PubMed/MEDLINE, Web of Science, and PsycINFO from 1980 through October 1st, 2017, for original peer-reviewed articles that investigated predictors of adherence to psychopharmacologic treatment among children (≤18-years-old) with a primary psychotic disorder, bipolar disorder, depression, recent suicide attempt, or psychiatric hospitalization. Effect sizes (ESs) for individual predictors were extracted and combined using DerSimonian-Laird random-effects meta-analysis. Meta-regression and moderator analyses were conducted to investigate subgroups. This review complied with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines.

RESULTS

A total of 28 studies (n = 180,870) met inclusion criteria; 65.9% (±20.9%) of children and adolescents with SMI were medication adherent. Adherence was associated with patient and family attitudes toward care, adherence to psychotherapy, and insight. Nonadherence was associated with illness severity, substance use, and attention-deficit/hyperactivity disorder. Heterogeneity was moderate-to-large for most ES estimates (I² > 50%). Age, sex, underlying diagnosis, and study methodology emerged as significant moderators.

CONCLUSION

Medication nonadherence among youth with SMI is highly prevalent. Children and adolescents with more severe illness and higher comorbidity burden are at greater risk for nonadherence. Positive interpersonal care processes and adherence to nonpharmacological treatment may be protective. These findings inform development of a risk profile for nonadherence among youth with SMI. Future prospective research is needed to address the shortcomings in the existing literature and inform interventions to improve adherence.

Addressing primary nonadherence: A collaboration between a community pharmacy and a large pediatric clinic

OBJECTIVES

To decrease nonadherence rates through the design and implementation of a collaborative prescription management program involving a community pharmacy and a large pediatric primary care center.

PRACTICE INNOVATION

Kroger and Cincinnati Children's Pediatric Primary Care Center collaborated to identify and address patients' barriers to filling new prescriptions. After filling new medications for clinic patients, pharmacists telephoned patients to inform them that their prescription was ready and to reinforce the importance of initiating the therapy. Pharmacists followed up with families to address barriers when prescriptions remained at the pharmacy after 48 hours. Pharmacists communicated with prescribers if prescriptions were not filled, allowing the clinic staff to follow up.

EVALUATION

The primary outcome of this prospective pilot study with a comparison group was primary nonadherence (PNA), defined as the proportion of patients who did not pick up prescriptions or a reasonable alternative within 30 days after the pharmacy received the prescription. Secondary outcomes were the impact on secondary nonadherence and identification of adherence barriers.

RESULTS

Fifty-nine patients were enrolled from November 2016 to April 2017. Characteristics between the intervention group and a standard-care group were similar. The majority of prescribed medications were for acute conditions, the average patient age was 4.9 years, and 86% of patients were covered by Medicaid. Intervention patients had significantly less PNA compared with the standard-care group (14.0% vs. 53.3%, respectively; P < 0.001). Intervention patients had significantly greater secondary adherence rates compared with standard-care patients (38.8% vs. 7%; P < 0.001). Common barriers likely resulting in PNA included lack of time, lack of urgency, transportation challenges, and cost.

CONCLUSION

Increased communication between the primary care provider and the community pharmacy, coupled with targeted patient-specific interventions before the initial fill of medications, resulted in significant reductions in PNA.