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Hsieh WL, Li IH, Liu WI. Effects of empowerment-based illness management on the medication adherence and recovery of persons with schizophrenia: A systematic review and meta-analysis. Int J Ment Health Nurs 2023. [PMID: 36788653 DOI: 10.1111/inm.13123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/18/2022] [Accepted: 01/16/2023] [Indexed: 02/16/2023]
Abstract
Medication adherence and recovery rates are <50% among persons with schizophrenia; therefore, this health concern needs attention. Empowerment is a vital element for behavioural change, but previous studies have presented different results and lack specific connotations about empowerment. Therefore, this study systematically reviewed and meta-analysed the effects of empowerment-based illness management on the medication adherence and recovery of persons with schizophrenia. The databases searched included the PROSPERO registration network, Cochrane Library, PubMed, Embase, CINAHL, PsycAricle, and Airiti Library. The research steps were based on PRISMA. RoB 2.0 was used for article quality evaluation, the effect size was calculated using RevMan software, and the random-effect model and standardized mean differences (SMD) were established. Eight randomized controlled trials (RCTs) involving 859 participants were used to investigate the effect of empowerment on medication adherence. The trials involved the use of effective strategies as inducing medication motivation, promoting self-medication management, and providing support resources. A moderate effect was observed (SMD = 0.58, 95% CI 0.18-0.99). Ten RCTs involving 1473 participants were used to investigate the effect of empowerment on recovery. These trials involved the use of such effective strategies as using self-strength, connecting external forces, understanding personal needs, and overcoming self-stigma. A moderate effect was observed (SMD = 0.55, 95% CI 0.10-0.99). Empowerment in illness management can effectively promote the medication adherence and recovery of persons with schizophrenia. In the future, nurses can use self-strength care to promote medication motivation and connect internal and external forces to assist a person's medication adherence and recovery.
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Affiliation(s)
- Wen-Ling Hsieh
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan.,Wan Fang Hospital, Taipei Medical University, Taipei City, Taiwan
| | - I-Hsien Li
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan.,Cardinal Tien Junior College of Healthcare and Management, New Taipei City, Taiwan
| | - Wen-I Liu
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan
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2
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Al Dameery K, Valsaraj BP, Qutishat M, Obeidat A, Alkhawaldeh A, Al Sabei S, Al Omari O, ALBashtawy M, Al Qadire M. Enhancing Medication Adherence Among Patients With Schizophrenia and Schizoaffective Disorder: Mobile App Intervention Study. SAGE Open Nurs 2023; 9:23779608231197269. [PMID: 37655277 PMCID: PMC10467252 DOI: 10.1177/23779608231197269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/16/2023] [Accepted: 08/05/2023] [Indexed: 09/02/2023] Open
Abstract
Introduction Technology has permeated every aspect of our existence and the mental health sector is not exempt from this. Objectives The aim of this study was to test the impact of using a mobile phone app (MyTherapy pill reminder and medication tracker) on medication adherence in patients with schizophrenia and/or schizoaffective disorder. Methods Time series design was used. Fifty-one participants were recruited from tertiary hospitals in Oman. The Medication Adherence Rating Scale was used for assessing medication adherence. The data related to medication adherence were collected at baseline, 3 months later and 3 months after installing the program on participants' smartphones. SPSS data set used to analyze the data. Results A repeated-measures ANOVA found no significant change in the level of adherence among patients with schizophrenia and schizoaffective disorders at the start and 12 weeks later when the mobile app was installed (p = .371). However, adherence scores improved significantly 12 weeks after installation of mobile app compared with the same group at the baseline and 12 weeks before the installation of mobile app (p < .001). Conclusion The mobile phone app was effective in improving the adherence level among patients. Installation of the program and teaching patients how to use it to improve their level of adherence is recommended.
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Affiliation(s)
| | | | | | - Arwa Obeidat
- College of Nursing, Sultan Qaboos University, Muscat, Oman
| | | | | | - Omar Al Omari
- College of Nursing, Sultan Qaboos University, Muscat, Oman
| | | | - Mohammad Al Qadire
- College of Nursing, Sultan Qaboos University, Muscat, Oman
- Princess Salma Faculty of Nursing, Al Al-Bayt University, Mafraq, Jordan
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3
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Papus M, Dima AL, Viprey M, Schott AM, Schneider MP, Novais T. Motivational interviewing to support medication adherence in adults with chronic conditions: Systematic review of randomized controlled trials. PATIENT EDUCATION AND COUNSELING 2022; 105:3186-3203. [PMID: 35779984 DOI: 10.1016/j.pec.2022.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To systematically review published randomized controlled trials (RCTs) assessing the efficacy of MI to support medication adherence in adults with chronic conditions. METHODS A systematic review (PROSPERO-CRD42020025374) was performed by searching in Pubmed/MEDLINE, PsycINFO, The Cochrane Library and Web of Science. Studies were included for the following: RCTs assessing the impact of MI on medication adherence among adults with chronic diseases. Two reviewers conducted independent screening of records and full-text articles published until July 2020. Quality was assessed with the Risk of Bias 2 tool for RCTs. RESULTS From 1262 records identified, 54 RCTs were included. The MI interventions were delivered alone or in combination with other interventions, and varied in mode of delivery (e.g. face-to-face, phone), exposure level (duration, number of sessions), and provider characteristics (profession, training). Most interventions were developed in infectious diseases (n = 16), cardiology (n = 14), psychiatry (n = 8), and endocrinology (n = 7). Medication adherence showed significant improvement in 23 RCTs, and other clinical outcomes were improved in 19 RCTs (e.g. risky behaviors, disease symptoms). CONCLUSIONS MI is an approach to medication adherence support with an increasing evidence base in several clinical domains and further potential for adaptation to different settings. PRACTICE IMPLICATIONS In further studies, particular attention should focus on methodological issues such as the populations of patients to include - patients with suboptimal adherence, the evaluation of fidelity to the MI spirit and components, and a sound measurement of medication adherence and clinical outcomes.
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Affiliation(s)
- Marlène Papus
- Pharmaceutical Unit, Charpennes Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alexandra L Dima
- Claude Bernard Lyon 1 University, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France
| | - Marie Viprey
- Claude Bernard Lyon 1 University, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Public Health department, Hospices Civils de Lyon, Lyon, France
| | - Anne-Marie Schott
- Claude Bernard Lyon 1 University, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France; Public Health department, Hospices Civils de Lyon, Lyon, France
| | - Marie Paule Schneider
- Chair of Medication Adherence and Interprofesionality, School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland; Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland
| | - Teddy Novais
- Pharmaceutical Unit, Charpennes Hospital, Hospices Civils de Lyon, Lyon, France; Claude Bernard Lyon 1 University, Research on Healthcare Performance (RESHAPE), INSERM U1290, Lyon, France.
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4
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Dong D, Mu TY, Xu JY, Dai JN, Zhou ZN, Zhang QZ, Shen CZ. A WeChat-based self-compassion training to improve the treatment adherence of patients with schizophrenia in China: Protocol for a randomized controlled trial. Front Psychol 2022; 13:931802. [PMID: 36110273 PMCID: PMC9469756 DOI: 10.3389/fpsyg.2022.931802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAt present, adherence to antipsychotic treatment is often poor, leading to the recurrence of symptoms. This increases the likelihood of the patient experiencing disability and thus increases the disease burden for the patient, their family, and society as a whole. However, to date, there is no clear evidence regarding the effect of medication adherence interventions on outcomes for patients with schizophrenia. Moreover, the traditional intervention methods are limited by manpower and resources in low- and middle-income countries. Recent studies have demonstrated that increasing a patient’s level of self-compassion may improve their treatment adherence. Online mental health care interventions have advantages in terms of feasibility and acceptability for patients with schizophrenia. In this regard, a WeChat-based self-compassion training protocol to improve patient treatment adherence was designed in this study and will be evaluated in the future to determine its impact on patients with schizophrenia.MethodsThe protocol for the randomized controlled trial (RCT) is based on the SPIRIT 2013 statement. This parallel RCT will aim to recruit 392 patients with schizophrenia who will be randomized at a 1:1 ratio into a 3-week intervention or control group. Both groups will receive routine care. The intervention group will also receive WeChat-based self-compassion training, which requires participants to complete three tasks every day, including a reading task, a meditation task, and a self-compassion journal task. The control group will receive WeChat-based psychological health education, which will only require participants to read positive articles about psychological health every day. Medication adherence, self-compassion, stigma, and social support will be measured at baseline (T0), immediately after the intervention (T1), and 3 weeks after the intervention (T2). Program feasibility will be evaluated throughout the course of the study, and acceptability will be measured immediately after the intervention (T1).Expected results:The intervention described here will address the barriers to accessing mental health care for people with schizophrenia, including patients’ desire for independent management, difficulty accessing providers, and concerns about privacy and stigma. The current study provides guidance for clinical nurses to carry out psychological intervention, with the ultimate aim of addressing the problems associated with a shortage of psychological professionals in low- and middle-income countries.
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Affiliation(s)
- Die Dong
- College of Nursing, Zhejiang Chinese Medical University, Hangzhou, China
| | - Ting-Yu Mu
- College of Nursing, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jia-Yi Xu
- College of Nursing, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jia-Ning Dai
- College of Nursing, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zhi-Nan Zhou
- College of Nursing, Zhejiang Chinese Medical University, Hangzhou, China
| | | | - Cui-Zhen Shen
- College of Nursing, Zhejiang Chinese Medical University, Hangzhou, China
- *Correspondence: Cui-Zhen Shen,
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Baker AL, Forbes E, Pohlman S, McCarter K. Behavioral Interventions to Reduce Cardiovascular Risk Among People with Severe Mental Disorder. Annu Rev Clin Psychol 2022; 18:99-124. [PMID: 35175861 DOI: 10.1146/annurev-clinpsy-072720-012042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cardiovascular disease (CVD) is the leading cause of death among people with severe mental disorder (SMD). CVD risk factors occur at the individual, health system, and socio-environmental levels and contribute not only to high rates of CVD but also to worsening mental health. While acknowledging this wider context, this review focuses on behavioral interventions for seven CVD risk behaviors-smoking, physical inactivity, excessive alcohol consumption, low fruit and vegetable intake, inadequate sleep, poor social participation, and poor medication adherence-that are common among people with SMD. We survey recent meta-reviews of the literature and then review additional key studies to provide clinical recommendations for behavioral interventions to reduce CVD risk among people with SMD. A transdiagnostic psychological approach from the start of mental health treatment, drawing upon multidisciplinary expertise to address multiple risk behaviors, is recommended. 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.
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Affiliation(s)
- Amanda L Baker
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia;
| | - Erin Forbes
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia;
| | - Sonja Pohlman
- School of Psychology, College of Engineering, Science and Environment, University of Newcastle, Callaghan, New South Wales, Australia
| | - Kristen McCarter
- School of Psychology, College of Engineering, Science and Environment, University of Newcastle, Callaghan, New South Wales, Australia
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6
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Cahaya N, Kristina SA, Widayanti AW, Green J. Interventions to Improve Medication Adherence in People with Schizophrenia: A Systematic Review. Patient Prefer Adherence 2022; 16:2431-2449. [PMID: 36072918 PMCID: PMC9444034 DOI: 10.2147/ppa.s378951] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Nonadherence to medications is very common in people with schizophrenia. Numerous methods have been implemented to improve medication adherence. The study aimed to determine what interventions have been used and to assess the effectiveness of these in improving medication adherence in people with schizophrenia. Two electronic databases (PubMed and Science Direct) and a manual search were used to locate RCT studies that examined interventions in medication adherence for schizophrenia, published between 2011 and 2022. The search was conducted using the terms (schizophrenia OR schizophrenic) AND (interventions OR adherence therapy) AND (medication adherence OR medication compliance). Sixteen studies were included, and relevant data were extracted and selected. Sixteen studies used interventions that involve family, health professionals (psychiatrists, psychologists, nurses, and pharmacists), SMS, and smart electronic reminders. Medication adherence was measured using medication refill records from hospital dispensing records or claim databases, electronic devices, plasma blood concentration, and participant self-reporting. Thirteen out of 15 studies showed significant improvements in adherence compared to routine care. The other three studies did not result in improved medication adherence. Interventions with diverse strategies delivered to individuals with schizophrenia showed the potential to reduce medication non-adherence in people with schizophrenia so that they can be utilized as an alternative to support treatment in people with schizophrenia in addition to antipsychotic medication. In future research strategies, it will be necessary to identify the main problems regarding nonadherence in people with schizophrenia individually and also identify the patient's perception of medication, illness, and behavior when taking medication in order to determine the next intervention that will be appropriate based on the patient's needs to improve adherence.
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Affiliation(s)
- Noor Cahaya
- Doctoral Program in Pharmacy, Faculty of Pharmacy, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Department of Pharmacy, Faculty of Mathematics and Science, Universitas Lambung Mangkurat, Banjarbaru, Indonesia
| | - Susi Ari Kristina
- Department of Pharmaceutics, Faculty of Pharmacy, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Correspondence: Susi Ari Kristina, Department of Pharmaceutics, Faculty of Pharmacy, Universitas Gadjah Mada, Sekip Utara, Yogyakarta, 55281, Indonesia, Email
| | - Anna Wahyuni Widayanti
- Department of Pharmaceutics, Faculty of Pharmacy, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - James Green
- School of Allied Health and Physical Activity for Health, Health Research Institute (HRI), University of Limerick, Limerick, Ireland
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Loots E, Goossens E, Vanwesemael T, Morrens M, Van Rompaey B, Dilles T. Interventions to Improve Medication Adherence in Patients with Schizophrenia or Bipolar Disorders: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10213. [PMID: 34639510 PMCID: PMC8508496 DOI: 10.3390/ijerph181910213] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/24/2021] [Accepted: 09/24/2021] [Indexed: 11/16/2022]
Abstract
Adherence to prescribed medication regimes improves outcomes for patients with severe mental illness such as schizophrenia or bipolar disorders. The aim of this systematic review and meta-analysis was to compare the effectiveness among interventions to improve medication adherence in patients with schizophrenia or bipolar disorders. Literature published in the last decade was searched for interventions studies to improve adherence in patients with schizophrenia or a bipolar disorder. Interventions were categorised on the basis of type, and the context and effectiveness of the interventions were described. Two review authors independently extracted and assessed data, following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions. The GRADEPro (McMaster University, 2020, Ontario, Canada) was used for assessing the quality of the evidence. Twenty-three publications met the selection criteria. Different types of interventions aiming to improve adherence were tested: educational, behavioural, family-based, technological, or a combination of previous types. Meta-analysis could be performed for 10 interventions. When considered separately by subgroups on the basis of intervention type, no significant differences were found in adherence among interventions (p = 0.29; I2 = 19.9%). This review concluded that successful interventions used a combination of behavioural and educational approaches that seem easy to implement in daily practice.
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Affiliation(s)
- Elke Loots
- Centre For Research and Innovation in Care (CRIC), Department of Nursing Science and Midwifery, Nurse and Pharmaceutical Care (NuPhaC), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (E.G.); (T.V.); (B.V.R.); (T.D.)
| | - Eva Goossens
- Centre For Research and Innovation in Care (CRIC), Department of Nursing Science and Midwifery, Nurse and Pharmaceutical Care (NuPhaC), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (E.G.); (T.V.); (B.V.R.); (T.D.)
- Department of Public Health and Primary Care, University of Leuven, 3000 Leuven, Belgium
- Research Foundation Flanders (FWO), 1000 Brussels, Belgium
- Department of Patient Care, Antwerp University Hospital (UZA), 2610 Antwerp, Belgium
| | - Toke Vanwesemael
- Centre For Research and Innovation in Care (CRIC), Department of Nursing Science and Midwifery, Nurse and Pharmaceutical Care (NuPhaC), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (E.G.); (T.V.); (B.V.R.); (T.D.)
| | - Manuel Morrens
- Faculty of Medicine and Health Sciences, Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, 2610 Antwerp, Belgium;
| | - Bart Van Rompaey
- Centre For Research and Innovation in Care (CRIC), Department of Nursing Science and Midwifery, Nurse and Pharmaceutical Care (NuPhaC), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (E.G.); (T.V.); (B.V.R.); (T.D.)
| | - Tinne Dilles
- Centre For Research and Innovation in Care (CRIC), Department of Nursing Science and Midwifery, Nurse and Pharmaceutical Care (NuPhaC), Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (E.G.); (T.V.); (B.V.R.); (T.D.)
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8
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Curto M, Fazio F, Ulivieri M, Navari S, Lionetto L, Baldessarini RJ. Improving adherence to pharmacological treatment for schizophrenia: a systematic assessment. Expert Opin Pharmacother 2021; 22:1143-1155. [PMID: 33543659 DOI: 10.1080/14656566.2021.1882996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Introduction: Poor adherence to pharmacological treatment is prevalent in schizophrenia, affecting more than half of patients at some time, with increased risks of clinical worsening, adverse outcomes, suicide, and increased resource utilization including hospitalization, with higher costs.Areas Covered: This review considers factors associated with treatment-nonadherence among schizophrenia patients, with a systematic evaluation of interventions aimed at improving adherence with an emphasis on evidence arising from their testing.Expert opinion: Several interventions have addressed factors empirically associated with treatment-nonadherence, including various drug-, patient - and clinical services-associated factors. They include long-acting injected (LAI) drug formulations, behavioral interventions, and technology-supported methods. Use of LAI antipsychotics and behavioral techniques aimed at incorporating medicine-taking into daily routines with electronic monitoring have been assessed relatively extensively. Mobile, digital applications including medication monitoring systems and artificial intelligence-based interactions are emerging but have been tested in few trials of limited quality with inconclusive results. Randomized, controlled, blinded trials based on clinically representative samples are needed to evaluate not only adherence, but also to test for clinically meaningful and sustained clinical benefits in schizophrenia patients, who are especially difficult to treat.
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Affiliation(s)
- Martina Curto
- Department of Mental Health, Rome, Italy.,International Consortium for Mood Psychotic & Mood Disorders Research, McLean Hospital, Belmont, MA, USA
| | - Francesco Fazio
- Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, New York, NY, USA
| | - Martina Ulivieri
- Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, New York, NY, USA
| | - Serena Navari
- Department of Mental Health, Colleferro (Rome), Italy
| | - Luana Lionetto
- Advanced Molecular Diagnostics Unit, Sant'Andrea Hospital, Rome, Italy
| | - Ross J Baldessarini
- International Consortium for Mood Psychotic & Mood Disorders Research, McLean Hospital, Belmont, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Warriach ZI, Sanchez-Gonzalez MA, Ferrer GF. Suicidal Behavior and Medication Adherence in Schizophrenic Patients. Cureus 2021; 13:e12473. [PMID: 33552789 PMCID: PMC7854315 DOI: 10.7759/cureus.12473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Suicide is one of the potential complications in the Schizophrenic patient population. This review article deals with the significance of antipsychotic medication compliance in decreasing suicidal behavior and hospitalizations in Schizophrenic patients. The medication adherence with second-generation antipsychotics (SGA) like clozapine and long-acting injectables (LAIs) like paliperidone is associated with decrease suicidal behavior and all-cause mortality in Schizophrenic patients. Concomitant treatment of depression and substance abuse disorder in this patient population is also associated with decreasing all-cause mortality and hospitalizations. On the other hand, long-term benzodiazepine use is associated with increase mortality in Schizophrenic patients. We also discuss some important physician intervention strategies to improve medication adherence in Schizophrenic patients like motivational interviewing (MI), behavioral tailoring (BT), and psychosocial interventions like cognitive behavior therapy (CBT).
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Affiliation(s)
- Zain I Warriach
- Department of Psychiatry, Larkin Community Hospital, Miami, USA
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10
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Kohn L, Christiaens W, Detraux J, De Lepeleire J, De Hert M, Gillain B, Delaunoit B, Savoye I, Mistiaen P, Jespers V. Barriers to Somatic Health Care for Persons With Severe Mental Illness in Belgium: A Qualitative Study of Patients' and Healthcare Professionals' Perspectives. Front Psychiatry 2021; 12:798530. [PMID: 35153863 PMCID: PMC8825501 DOI: 10.3389/fpsyt.2021.798530] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/03/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND A huge and still growing mortality gap between people with severe mental illness (SMI) and the general population exists. Physical illnesses, mainly cardiovascular diseases, substantially contribute to the high mortality rates in patients with SMI. Disparities in somatic health care access, utilisation, and provision contribute to these poor physical health outcomes. METHODS A qualitative study, using semi-structured interviews, was set up to explore SMI patients' and healthcare professionals' perspectives on somatic health care in different psychiatric settings of the three Belgian regions (Flanders, Brussels, Wallonia). Interviews were digitally recorded and transcribed prior to qualitative inductive thematic analysis, using Nvivo software. The COnsolidated criteria for REporting Qualitative research (COREQ) were used for reporting methods and findings. RESULTS Collaboration and information flows between psychiatric healthcare professionals, non-psychiatric healthcare professionals, and persons with SMI were troublesome. This seemed to be mainly due to stigma and prejudice and challenging communication and data transfer. Lack of sufficient training and experience to identify and treat somatic health problems in people with SMI (for psychiatrists and psychiatric nurses) and lack of psychiatric knowledge and feeling or sensitivity for psychiatric patients (for non-psychiatric healthcare professionals) further complicated adequate somatic health care. Finally, optimal somatic follow-up of patients with SMI was hampered by organisational problems (unavailability of equipment, unadapted infrastructure, understaffing, hospital pharmacy issues, and insufficient health promotion/lifestyle interventions), patient-related issues (unawareness of physical problems, non-adherence, need for accompaniment) and financial barriers. CONCLUSION There is an urgent need for integrated somatic and mental healthcare systems and a cultural change. Psychiatrists and primary care providers continue to consider the mental and physical health of their patients as mutually exclusive responsibilities due to a lack of sufficient training and experience, poor or absent liaison links, time constraints and organisational and financial barriers. Modifying these aspects will improve the quality of somatic health care for these vulnerable patients.
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Affiliation(s)
- Laurence Kohn
- Belgian Health Care Knowledge Centre, Brussels, Belgium
| | | | - Johan Detraux
- Department of Neurosciences, Public Health Psychiatry, University Psychiatric Center, Catholic University of Leuven, Kortenberg, Belgium
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, Catholic University of Leuven, Leuven, Belgium
| | - Marc De Hert
- Department of Neurosciences, Center for Clinical Psychiatry, University Psychiatric Center, Catholic University of Leuven, Kortenberg, Belgium.,Antwerp Health Law and Ethics Chair, University of Antwerp, Antwerp, Belgium
| | - Benoit Gillain
- Société Royale de Santé Mentale de Belgique, Ottignies, Belgium
| | | | | | | | - Vicky Jespers
- Belgian Health Care Knowledge Centre, Brussels, Belgium
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11
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Bröms G, Cahling L, Berntsson A, Öhrmalm L. Psychoeducation and motivational interviewing to reduce relapses and increase patients' involvement in antipsychotic treatment: interventional study. BJPsych Bull 2020; 44:265-268. [PMID: 32290892 PMCID: PMC7684775 DOI: 10.1192/bjb.2020.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
AIMS AND METHOD To assess whether the combination of motivational interviewing and psychoeducation affects relapse rate and stimulates involvement of people with psychosis in their treatment. We conducted an interventional study including patients with schizophrenia or schizoaffective disorder treated with oral antipsychotics, without previous experience of long-acting injectable antipsychotics (LAIs). They were randomised to either psychoeducation with motivational interviewing or a control group. Hospital admissions 18 months before and after the intervention, and switches to LAIs 18 months after the intervention, were recorded. RESULTS The two groups each comprised 101 participants. Fourteen from the intervention group and seven from the control group switched to LAIs. Five in the intervention group instigated the switch themselves, compared with zero controls (P = 0.06). Fourteen in the intervention group were readmitted to hospital during follow-up, compared with 23 in the control group (P = 0.14). CLINICAL IMPLICATIONS Psychoeducation with motivational interviewing may increase patients' involvement in their treatment and reduce the relapse frequency.
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Affiliation(s)
- Gabriella Bröms
- Unit of Clinical Epidemiology, Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Lars Öhrmalm
- PRIMA Child and Adult Psychiatry, Stockholm, Sweden.,Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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12
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Total Cost of Therapy-Based Care Versus a Brokerage Model of Case Management for Persons With a Serious Mental Illness Served in the Community. J Behav Health Serv Res 2020; 48:330-341. [PMID: 32725460 DOI: 10.1007/s11414-020-09722-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A five-year evaluation compared total Medicaid and General Fund behavioral health care costs of a behavioral health home (BHH) model with those of a brokerage model of case management (treatment-as-usual) for the community care of adults with a serious mental illness. The BHH was an interprofessional, team-based intervention that used cognitive behavioral therapy, motivational interviewing, and dialectical behavioral therapy skills as primary interventions. By the third full year, the BHH total cost was less than half that of case management. The difference was due largely to less utilization of inpatient and community residential services among those served by the BHH. Results are limited by the non-randomized assignment among the groups and the availability of only aggregate data, but they strongly suggest the value of further examination of the effectiveness and cost of BHH versus case management-based interventions in a community mental health setting.
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Barnes TR, Drake R, Paton C, Cooper SJ, Deakin B, Ferrier IN, Gregory CJ, Haddad PM, Howes OD, Jones I, Joyce EM, Lewis S, Lingford-Hughes A, MacCabe JH, Owens DC, Patel MX, Sinclair JM, Stone JM, Talbot PS, Upthegrove R, Wieck A, Yung AR. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2020; 34:3-78. [PMID: 31829775 DOI: 10.1177/0269881119889296] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.
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Affiliation(s)
- Thomas Re Barnes
- Emeritus Professor of Clinical Psychiatry, Division of Psychiatry, Imperial College London, and Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Richard Drake
- Clinical Lead for Mental Health in Working Age Adults, Health Innovation Manchester, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Carol Paton
- Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Stephen J Cooper
- Emeritus Professor of Psychiatry, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Bill Deakin
- Professor of Psychiatry, Neuroscience & Psychiatry Unit, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - I Nicol Ferrier
- Emeritus Professor of Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine J Gregory
- Honorary Clinical Research Fellow, University of Manchester and Higher Trainee in Child and Adolescent Psychiatry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter M Haddad
- Honorary Professor of Psychiatry, Division of Psychology and Mental Health, University of Manchester, UK and Senior Consultant Psychiatrist, Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Oliver D Howes
- Professor of Molecular Psychiatry, Imperial College London and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ian Jones
- Professor of Psychiatry and Director, National Centre of Mental Health, Cardiff University, Cardiff, UK
| | - Eileen M Joyce
- Professor of Neuropsychiatry, UCL Queen Square Institute of Neurology, London, UK
| | - Shôn Lewis
- Professor of Adult Psychiatry, Faculty of Biology, Medicine and Health, The University of Manchester, UK, and Mental Health Academic Lead, Health Innovation Manchester, Manchester, UK
| | - Anne Lingford-Hughes
- Professor of Addiction Biology and Honorary Consultant Psychiatrist, Imperial College London and Central North West London NHS Foundation Trust, London, UK
| | - James H MacCabe
- Professor of Epidemiology and Therapeutics, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and Honorary Consultant Psychiatrist, National Psychosis Service, South London and Maudsley NHS Foundation Trust, Beckenham, UK
| | - David Cunningham Owens
- Professor of Clinical Psychiatry, University of Edinburgh. Honorary Consultant Psychiatrist, Royal Edinburgh Hospital, Edinburgh, UK
| | - Maxine X Patel
- Honorary Clinical Senior Lecturer, King's College London, Institute of Psychiatry, Psychology and Neuroscience and Consultant Psychiatrist, Oxleas NHS Foundation Trust, London, UK
| | - Julia Ma Sinclair
- Professor of Addiction Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James M Stone
- Clinical Senior Lecturer and Honorary Consultant Psychiatrist, King's College London, Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Trust, London, UK
| | - Peter S Talbot
- Senior Lecturer and Honorary Consultant Psychiatrist, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Rachel Upthegrove
- Professor of Psychiatry and Youth Mental Health, University of Birmingham and Consultant Psychiatrist, Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Angelika Wieck
- Honorary Consultant in Perinatal Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Alison R Yung
- Professor of Psychiatry, University of Manchester, School of Health Sciences, Manchester, UK and Centre for Youth Mental Health, University of Melbourne, Australia, and Honorary Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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14
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Dobber J, Latour C, van Meijel B, Ter Riet G, Barkhof E, Peters R, Scholte Op Reimer W, de Haan L. Active Ingredients and Mechanisms of Change in Motivational Interviewing for Medication Adherence. A Mixed Methods Study of Patient-Therapist Interaction in Patients With Schizophrenia. Front Psychiatry 2020; 11:78. [PMID: 32265746 PMCID: PMC7105777 DOI: 10.3389/fpsyt.2020.00078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 01/31/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Trials studying Motivational Interviewing (MI) to improve medication adherence in patients with schizophrenia showed mixed results. Moreover, it is unknown which active MI-ingredients are associated with mechanisms of change in patients with schizophrenia. To enhance the effect of MI for patients with schizophrenia, we studied MI's active ingredients and its working mechanisms. METHODS First, based on MI literature, we developed a model of potential active ingredients and mechanisms of change of MI in patients with schizophrenia. We used this model in a qualitative multiple case study to analyze the application of the active ingredients and the occurrence of mechanisms of change. We studied the cases of fourteen patients with schizophrenia who participated in a study on the effect of MI on medication adherence. Second, we used the Generalized Sequential Querier (GSEQ 5.1) to perform a sequential analysis of the MI-conversations aiming to assess the transitional probabilities between therapist use of MI-techniques and subsequent patient reactions in terms of change talk and sustain talk. RESULTS We found the therapist factor "a trusting relationship and empathy" important to enable sufficient depth in the conversation to allow for the opportunity of triggering mechanisms of change. The most important conversational techniques we observed that shape the hypothesized active ingredients are reflections and questions addressing medication adherent behavior or intentions, which approximately 70% of the time was followed by "patient change talk". Surprisingly, sequential MI-consistent therapist behavior like "affirmation" and "emphasizing control" was only about 6% of the time followed by patient change talk. If the active ingredients were embedded in more comprehensive MI-strategies they had more impact on the mechanisms of change. CONCLUSIONS Mechanisms of change mostly occurred after an interaction of active ingredients contributed by both therapist and patient. Our model of active ingredients and mechanisms of change enabled us to see "MI at work" in the MI-sessions under study, and this model may help practitioners to shape their MI-strategies to a potentially more effective MI.
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Affiliation(s)
- Jos Dobber
- ACHIEVE Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Corine Latour
- ACHIEVE Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Berno van Meijel
- Research Group Mental Health Nursing, Inholland University of Applied Sciences, Amsterdam, Netherlands.,Department of Psychiatry, Amsterdam UMC (VUmc), Amsterdam Public Health Research Institute, Amsterdam, Netherlands.,Parnassia Academy, Parnassia Psychiatric Institute, The Hague, Netherlands
| | - Gerben Ter Riet
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Ron Peters
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Wilma Scholte Op Reimer
- ACHIEVE Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands.,Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Lieuwe de Haan
- Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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15
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Hunt GE, Siegfried N, Morley K, Brooke‐Sumner C, Cleary M. Psychosocial interventions for people with both severe mental illness and substance misuse. Cochrane Database Syst Rev 2019; 12:CD001088. [PMID: 31829430 PMCID: PMC6906736 DOI: 10.1002/14651858.cd001088.pub4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Even low levels of substance misuse by people with a severe mental illness can have detrimental effects. OBJECTIVES To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care. SEARCH METHODS The Information Specialist of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (2 May 2018), which is based on regular searches of major medical and scientific databases. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness. DATA COLLECTION AND ANALYSIS Review authors independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. Where meta-analyses were possible, we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison. MAIN RESULTS Our review now includes 41 trials with a total of 4024 participants. We have identified nine comparisons within the included trials and present a summary of our main findings for seven of these below. We were unable to summarise many findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low- or very-low quality due to high or unclear risks of bias because of poor trial methods, or inadequately reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals. 1. Integrated models of care versus standard care (36 months) No clear differences were found between treatment groups for loss to treatment (RR 1.09, 95% CI 0.82 to 1.45; participants = 603; studies = 3; low-quality evidence), death (RR 1.18, 95% CI 0.39 to 3.57; participants = 421; studies = 2; low-quality evidence), alcohol use (RR 1.15, 95% CI 0.84 to 1.56; participants = 143; studies = 1; low-quality evidence), substance use (drug) (RR 0.89, 95% CI 0.63 to 1.25; participants = 85; studies = 1; low-quality evidence), global assessment of functioning (GAF) scores (MD 0.40, 95% CI -2.47 to 3.27; participants = 170; studies = 1; low-quality evidence), or general life satisfaction (QOLI) scores (MD 0.10, 95% CI -0.18 to 0.38; participants = 373; studies = 2; moderate-quality evidence). 2. Non-integrated models of care versus standard care There was no clear difference between treatment groups for numbers lost to treatment at 12 months (RR 1.21, 95% CI 0.73 to 1.99; participants = 134; studies = 3; very low-quality evidence). 3. Cognitive behavioural therapy (CBT) versus standard care There was no clear difference between treatment groups for numbers lost to treatment at three months (RR 1.12, 95% CI 0.44 to 2.86; participants = 152; studies = 2; low-quality evidence), cannabis use at six months (RR 1.30, 95% CI 0.79 to 2.15; participants = 47; studies = 1; very low-quality evidence) or mental state insight (IS) scores by three months (MD 0.52, 95% CI -0.78 to 1.82; participants = 105; studies = 1; low-quality evidence). 4. Contingency management versus standard care We found no clear differences between treatment groups for numbers lost to treatment at three months (RR 1.55, 95% CI 1.13 to 2.11; participants = 255; studies = 2; moderate-quality evidence), number of stimulant positive urine tests at six months (RR 0.83, 95% CI 0.65 to 1.06; participants = 176; studies = 1) or hospitalisations (RR 0.21, 95% CI 0.05 to 0.93; participants = 176; studies = 1); both low-quality evidence. 5. Motivational interviewing (MI) versus standard care We found no clear differences between treatment groups for numbers lost to treatment at six months (RR 1.71, 95% CI 0.63 to 4.64; participants = 62; studies = 1). A clear difference, favouring MI, was observed for abstaining from alcohol (RR 0.36, 95% CI 0.17 to 0.75; participants = 28; studies = 1) but not other substances (MD -0.07, 95% CI -0.56 to 0.42; participants = 89; studies = 1), and no differences were observed in mental state general severity (SCL-90-R) scores (MD -0.19, 95% CI -0.59 to 0.21; participants = 30; studies = 1). All very low-quality evidence. 6. Skills training versus standard care At 12 months, there were no clear differences between treatment groups for numbers lost to treatment (RR 1.42, 95% CI 0.20 to 10.10; participants = 122; studies = 3) or death (RR 0.15, 95% CI 0.02 to 1.42; participants = 121; studies = 1). Very low-quality, and low-quality evidence, respectively. 7. CBT + MI versus standard care At 12 months, there was no clear difference between treatment groups for numbers lost to treatment (RR 0.99, 95% CI 0.62 to 1.59; participants = 327; studies = 1; low-quality evidence), number of deaths (RR 0.60, 95% CI 0.20 to 1.76; participants = 603; studies = 4; low-quality evidence), relapse (RR 0.50, 95% CI 0.24 to 1.04; participants = 36; studies = 1; very low-quality evidence), or GAF scores (MD 1.24, 95% CI -1.86 to 4.34; participants = 445; studies = 4; very low-quality evidence). There was also no clear difference in reduction of drug use by six months (MD 0.19, 95% CI -0.22 to 0.60; participants = 119; studies = 1; low-quality evidence). AUTHORS' CONCLUSIONS We included 41 RCTs but were unable to use much data for analyses. There is currently no high-quality evidence to support any one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high-quality trials are required which address these concerns and improve the evidence in this important area.
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Affiliation(s)
- Glenn E Hunt
- The University of SydneyDiscipline of PsychiatryConcord Centre for Mental HealthHospital RoadSydneyNSWAustralia2139
| | - Nandi Siegfried
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitTybergCape TownSouth Africa
| | - Kirsten Morley
- The University of SydneyAddiction MedicineSydneyAustralia
| | - Carrie Brooke‐Sumner
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitTybergCape TownSouth Africa
| | - Michelle Cleary
- University of TasmaniaSchool of Nursing, College of Health and MedicineSydney, NSWAustralia
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16
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Reimer J, Kuhn J, Wietfeld R, Janetzky W, Leopold K. [Motivational interviewing : A possibility for doctor-patient communication in schizophrenia?]. DER NERVENARZT 2019; 90:1144-1153. [PMID: 30941459 DOI: 10.1007/s00115-019-0702-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Motivational interviewing (MI) has become established nowadays as an approach for a cooperative style of conversation to promote intrinsic motivation for change by exploring and resolving ambivalences. The change of addictive behavior is no longer sought by exerting pressure or lecturing/converting attempts of convincing or persuasion but by activating existing but "buried" or newly acquired self-motivation to change. The MI is now also used to change the treatment of other health-related behavior and chronic diseases, including schizophrenic disorders. Compared to the efficacy of MI in the addiction area, the data situation in schizophrenic patients is still insufficient. According to the available studies, MI can positively influence important aspects of disease-related impairments, such as medication adherence, the frequency and severity of psychotic relapses, the duration of hospitalization, the level of function, insight into the disease and cognitive rehabilitation. The practical implementation of MI requires a good knowledge of the method as well as changes in treatment principles and work processes.
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Affiliation(s)
- Jens Reimer
- Zentrum für Psychosoziale Medizin Gesundheit Nord, 28102, Bremen, Deutschland. .,Klinikum Bremen-Ost, Züricher Str. 40, 28325, Bremen, Deutschland. .,Zentrum für Interdisziplinäre Suchtforschung, Universitätsklinikum Hamburg-Eppendorf, Klinik für Psychiatrie und Psychotherapie, Universität Hamburg, Hamburg, Deutschland.
| | - Jens Kuhn
- Klinik für Psychiatrie, Psychotherapie und Psychosomatik, Johanniter Krankenhaus Oberhausen, Evangelischer Klinikverbund Niederrhein gGmbH, Oberhausen, Deutschland.,Klinik für Psychiatrie und Psychotherapie, Uniklinik Köln, Köln, Deutschland
| | - Rita Wietfeld
- Psychotherapie, Praxis Neurologie und Psychiatrie, Witten, Deutschland
| | | | - Karolina Leopold
- Psychiatrie, Psychotherapie und Psychosomatik, Vivantes Klinikum am Urban, Berlin, Deutschland
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17
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Magill N, Knight R, McCrone P, Ismail K, Landau S. A scoping review of the problems and solutions associated with contamination in trials of complex interventions in mental health. BMC Med Res Methodol 2019; 19:4. [PMID: 30616508 PMCID: PMC6323722 DOI: 10.1186/s12874-018-0646-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 12/17/2018] [Indexed: 11/23/2022] Open
Abstract
Background In a randomised controlled trial, contamination is defined as the receipt of active intervention amongst participants in the control arm. This review assessed the processes leading to contamination, its typical quantity, methods used to mitigate it, and impact of use of cluster randomisation to prevent it on study findings in trials of complex interventions in mental health. Methods This is a scoping review of trial design approaches and methods of study conduct to address contamination. Studies included were randomised controlled trials of complex interventions in mental health that described the process leading to, amount of, or solution used to counter contamination. The Medline, Embase, and PsycInfo databases were searched for trials published between 2000 and 2015. Risk of bias was assessed using the Jadad score and domains recommended by Cochrane plus some relevant to cluster randomised trials. Results Two hundred and thirty-four articles were included in the review. The main processes that led to contamination were health professionals delivering both active and comparator treatments and communication among clinicians and participants from the different trial arms. Twenty-three trials (10%) measured binary treatment receipt in the control arm with median 13% of participants found to be contaminated (IQR 5–33%). The most common design approach for dealing with contamination was the use of cluster randomisation (n = 93). In addition, many researchers used simple trial conduct methods to minimise contamination due to suspected contamination processes, such as organising for each clinician to provide only one treatment and separating trial arms spatially or temporally. There was little evidence for a relationship between cluster randomisation to avoid contamination and size of treatment effect estimate. Conclusion There was some evidence of modest levels of treatment contamination with a large range, although a minority of studies reported the amount of contamination. A limitation was that many trials described the problem in little detail. Overall there is a need for greater measurement and reporting of treatment receipt in the control arm of trials. Researchers should be aware of trial conduct methods that can be used to minimise contamination without resorting to cluster randomisation. Electronic supplementary material The online version of this article (10.1186/s12874-018-0646-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicholas Magill
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, 16 De Crespigny Park, London, SE5 8AF, United Kingdom. .,Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK.
| | - Ruth Knight
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, 16 De Crespigny Park, London, SE5 8AF, United Kingdom
| | - Paul McCrone
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Khalida Ismail
- Institute of Diabetes, Endocrinology and Obesity, King's Health Partners, London, UK
| | - Sabine Landau
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, 16 De Crespigny Park, London, SE5 8AF, United Kingdom
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18
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Wong-Anuchit C, Chantamit-O-Pas C, Schneider JK, Mills AC. Motivational Interviewing-Based Compliance/Adherence Therapy Interventions to Improve Psychiatric Symptoms of People With Severe Mental Illness: Meta-Analysis. J Am Psychiatr Nurses Assoc 2019; 25:122-133. [PMID: 29504450 DOI: 10.1177/1078390318761790] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Nonadherence is the leading cause of relapse in mental illness. No quantitative synthesis of multiple studies has been conducted to determine the effect of motivational interviewing (MI)-based compliance/adherence therapy (CAT) interventions on people with severe mental illness. OBJECTIVE To synthesize the studies that examined the effectiveness of MI-based CAT interventions to improve psychiatric symptoms. DESIGN Quantitative meta-analysis. RESULTS Sixteen primary studies were retrieved ( N =1267 participants). MI-based CAT interventions significantly improved psychiatric symptoms with a moderate effect size (ES) of .45. Longer sessions and higher intervention doses showed significantly greater ESs than shorter sessions and lower doses. ESs were significantly lower when participants were older and when there was a longer period between the intervention and outcome measurement. CONCLUSIONS These findings support the effectiveness of MI-based CAT interventions. Session length and dose effect should be considered when tailoring MI to clients.
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Affiliation(s)
| | | | | | - Andrew C Mills
- 4 Andrew C. Mills, PhD, RN, Mahasarakham University, Mahasarakham, Thailand
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19
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Cochran G, Field C, Karp J, Seybert AL, Chen Q, Ringwald W, Hruschak V, Chickering S, Kincman J, Jaber A, Tarter R. A community pharmacy intervention for opioid medication misuse: A pilot randomized clinical trial. J Am Pharm Assoc (2003) 2018; 58:395-403. [PMID: 29691197 PMCID: PMC6035879 DOI: 10.1016/j.japh.2018.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/19/2018] [Accepted: 03/19/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Community pharmacy continues to play a crucial role in the national response to the opioid epidemic. The purpose of this article is to describe the protocol for a pilot study that is examining the feasibility and acceptability of the Motivational Intervention-Medication Therapy Management (MI-MTM) model. This study also examines the preliminary clinical effect of MI-MTM for improving opioid medication misuse and patient activation in self-management of health conditions that increase risk for misuse. DESIGN MI-MTM is a pharmacy-based integrated care model made up of 4 evidence-based practices: medication therapy management; brief motivational intervention; patient navigation; and naloxone training and referral. To test MI-MTM compared with Standard Medication Counseling (SMC), we are conducting a 2-group randomized single-blinded controlled trial with assessments at 3 time points. SETTING AND PARTICIPANTS The study is being conducted within a western Pennsylvania university-based community pharmacy with 46 patients with opioid misuse (MI-MTM = 23; SMC = 23). MAIN OUTCOME MEASURES Feasibility will be measured by capturing patient completion rate of MI-MTM sessions. Acceptability will be measured by administering satisfaction surveys regarding pharmacist and patient navigator services. Acceptability will also be captured by conducting intensive qualitative interviews. Preliminary effect of the intervention on misuse will be measured with the use of the Prescription Opioid Misuse Index and the Opioid Compliance Checklist. Activation in self-management will be measured with the use of the Patient Activation Measure. RESULTS This project is currently recruiting, and results are to come. CONCLUSION This study is the first in the United States to implement an evidence-based integrated behavioral intervention into the community pharmacy setting to address opioid medication misuse among pharmacy patients. The results of this study will provide necessary foundational data that allow further testing of this intervention model in a larger trial.
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Affiliation(s)
- Gerald Cochran
- University of Pittsburgh, School of Social Work, School of Medicine, Department of Psychiatry, 2117 Cathedral of Learning, 4200 Fifth Ave, Pittsburgh, PA 15260, Phone: 412-624-2325, Fax: 412-624-6323,
| | - Craig Field
- University of Texas, El Paso, Department of Psychology, El Paso, TX
| | - Jordan Karp
- University of Pittsburgh, School of Medicine, Department of Psychiatry, Pittsburgh, PA
| | - Amy L. Seybert
- University of Pittsburgh, School of Pharmacy, Pittsburgh, PA
| | - Qi Chen
- University of Pittsburgh, School of Social Work, Pittsburgh, PA
| | | | | | | | | | | | - Ralph Tarter
- University of Pittsburgh, School of Pharmacy, Pittsburgh, PA
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20
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Arafat SMY, Mali B, Akter H. Proportion and reasons for medication non-compliance among schizophrenics: A cross-sectional observation in a tertiary care hospital of Bangladesh. Asian J Psychiatr 2018; 35:52-54. [PMID: 29783135 DOI: 10.1016/j.ajp.2018.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 04/27/2018] [Accepted: 05/07/2018] [Indexed: 11/18/2022]
Affiliation(s)
- S M Y Arafat
- Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.
| | - B Mali
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.
| | - H Akter
- Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.
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21
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Dobber J, Latour C, de Haan L, Scholte op Reimer W, Peters R, Barkhof E, van Meijel B. Medication adherence in patients with schizophrenia: a qualitative study of the patient process in motivational interviewing. BMC Psychiatry 2018; 18:135. [PMID: 29776393 PMCID: PMC5960122 DOI: 10.1186/s12888-018-1724-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 05/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Motivational interviewing (MI) may be an effective intervention to improve medication adherence in patients with schizophrenia. However, for this patient group, mixed results have been found in randomized controlled trials. Furthermore, the process of becoming (more) motivated for long-term medication adherence in patients with schizophrenia is largely unexplored. METHOD We performed a qualitative multiple case study of MI-sessions to analyse the interaction process affecting motivation in patients with schizophrenia. Fourteen cases of patients with schizophrenia, who recently experienced a psychotic relapse after medication-nonadherence, were studied, comprising 66 audio-recorded MI-sessions. In the MI-sessions, the patients expressed their cognitions on medication. We used these cognitions to detect the different courses (or patterns) of the patients' ambivalence during the MI-intervention. We distinguished successful and unsuccessful cases, and used the cross-case-analysis to identify success factors to reach positive effects of MI. RESULTS Based on the expressed cognitions on medication, we found four different patterns of the patient process. We also found three success factors for the intervention, which were a trusting relationship between patient and therapist, the therapist's ability to adapt his MI-strategy to the patient's process, and relating patient values to long-term medication adherence. CONCLUSIONS The success of an MI-intervention for medication adherence in patients with schizophrenia can be explained by well-defined success factors. Adherence may improve if therapists consider these factors during MI-sessions.
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Affiliation(s)
- Jos Dobber
- ACHIEVE Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Tafelbergweg 51, 1105 BD, Amsterdam, The Netherlands.
| | - Corine Latour
- grid.431204.0ACHIEVE Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Tafelbergweg 51, 1105 BD Amsterdam, The Netherlands
| | - Lieuwe de Haan
- 0000000084992262grid.7177.6Department of Psychiatry, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Wilma Scholte op Reimer
- grid.431204.0ACHIEVE Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Tafelbergweg 51, 1105 BD Amsterdam, The Netherlands ,0000000084992262grid.7177.6Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Ron Peters
- 0000000084992262grid.7177.6Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Emile Barkhof
- 0000 0004 0501 8787grid.468622.cGGZ Rivierduinen, Sandifortdreef 19, 2333 ZZ Leiden, The Netherlands
| | - Berno van Meijel
- grid.448984.dInholland University of Applied Sciences, De Boelelaan 1109, 1081 HV Amsterdam, The Netherlands ,0000 0004 0435 165Xgrid.16872.3aDepartment of Psychiatry, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands ,Parnassia Psychiatric Institute, Monterseweg 93, 2553 RJ The Hague, The Netherlands
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Khorassani F, Tellier S, Tsapepas D. Pharmacist's Role in Improving Medication Adherence in Transplant Recipients With Comorbid Psychiatric Disorders. J Pharm Pract 2018; 32:568-578. [PMID: 29554846 DOI: 10.1177/0897190018764074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Medication nonadherence rates are high in both the transplant and psychiatric populations. The consequence of medication nonadherence posttransplant is graft rejection and psychiatric decompensation, highlighting the importance of optimizing adherence to medication regimens. Pharmacists may work with transplant patients with psychiatric comorbidity to improve medication adherence through identifying patient-specific barriers and recommending an appropriate intervention. Multiple evidence-based practices for improving nonadherence have been detailed in the transplant and psychiatric population. Medication adherence aids, medication management, patient education, and motivational interviewing are all strategies that may be used to improve adherence. Selecting which interventions to make will be based on the reasons for a patient's nonadherence. Most patients benefit from medication management, patient education, and medication adherence aids. Selection of medication adherence aids may be based on patient demographics, technology literacy, and preference. Motivational interviewing may be considered in patients with intentional nonadherence relating to a lack of insight into their illness or the importance of taking medication. Pharmacists may promote adherence and potentially improve patient outcomes in transplant recipients with comorbid psychiatric disorders through assisting patients with designing a tailored medication adherence plan.
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Affiliation(s)
- Farah Khorassani
- Department of Clinical Health Professions, St John's University College of Pharmacy and Health Sciences, Queens, NY, USA.,Department of Pharmacy, Bellevue Hospital Center, New York, NY, USA
| | - Shannon Tellier
- Department of Pharmacy Practice and Clinical Sciences, Stony Brook University School of Pharmacy and Pharmaceutical Sciences, Stony Brook, NY, USA
| | - Demetra Tsapepas
- Department of Transplantation Surgery, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
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23
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Kreyenbuhl J, Record EJ, Palmer-Bacon J. A review of behavioral tailoring strategies for improving medication adherence in serious mental illness. DIALOGUES IN CLINICAL NEUROSCIENCE 2017. [PMID: 27489459 PMCID: PMC4969706 DOI: 10.31887/dcns.2016.18.2/jkreyenbuhl] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Nonadherence to psychopharmacological treatments poses a significant challenge to treatment success in individuals with serious mental illness, with upwards of 60% of people not taking their psychiatric medications as prescribed. Nonadherence is associated with adverse outcomes, including exacerbation of psychiatric symptoms, impaired functioning, increased hospitalizations and emergency room use, and increased health care costs. Whereas interventions using psychoeducation or cognitive approaches, such as motivational interviewing, have largely proven ineffective in improving adherence, approaches employing behavioral tailoring that incorporate medication taking into the daily routine and/or use environmental supports have shown promise. Recently, adherence-enhancing behavioral tailoring interventions that utilize novel technologies, such as electronic monitors and mobile phones, have been developed. Although interventions utilizing these platforms have the potential for widespread dissemination to a broad range of individuals, most require further empirical testing. This paper reviews selected behavioral tailoring strategies that aim to improve medication adherence and other functional outcomes among individuals with serious mental illness.
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Affiliation(s)
- Julie Kreyenbuhl
- University of Maryland School of Medicine, Department of Psychiatry, Division of Psychiatric Services Research, Baltimore, Maryland, USA ; VA Capitol Healthcare Network (VISN 5) Mental lllness Research, Education, and Clinical Center (MIRECC), Baltimore, Maryland, USA
| | | | - Jessica Palmer-Bacon
- University of Maryland School of Medicine, Department of Psychiatry, Division of Psychiatric Services Research, Baltimore, Maryland, USA; University of Maryland School of edicine, Baltimore, Maryland, USA
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24
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Cochran GT, Engel RJ, Hruschak VJ, Tarter RE. Prescription Opioid Misuse Among Rural Community Pharmacy Patients: Pilot Study for Screening and Implications for Future Practice and Research. J Pharm Pract 2017; 30:498-505. [PMID: 27402634 PMCID: PMC5219955 DOI: 10.1177/0897190016656673] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Opioid misuse imposes a disproportionately heavy burden on individuals living in rural areas. Community pharmacy has the potential to expand and coordinate with health professionals to identify and intervene with those who misuse opioids. OBJECTIVE Rural and urban community pharmacy patients were recruited in this pilot project to describe and compare patterns of opioid misuse. METHODS We administered a health screening survey in 4 community pharmacies among patients filling opioid medications. Univariate statistics were used to assess differences in health characteristics and opioid medication misuse behaviors between rural and urban respondents. Multivariable statistics were used to identify risk factors associated with rural and urban opioid misuse. RESULTS A total of 333 participants completed the survey. Participants in rural settings had poorer overall health, higher pain levels, lower education, and a higher rate of unemployment compared to patients in urban pharmacies. Rural respondents with illicit drug use (adjustable odds ratio [aOR]: 14.34, 95% confidence interval [CI] = 2.16-95.38), posttraumatic stress disorder (aOR: 5.44, 95% CI = 1.52-19.50), and ≤high school education (aOR: 6.68, 95% CI = 1.06-42.21) had increased risk for opioid misuse. CONCLUSIONS Community pharmacy represents a promising resource for potential identification of opioid misuse, particularly in rural communities. Continued research must extend these findings and work to establish collaborative services in rural settings.
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Affiliation(s)
- Gerald T Cochran
- 1 Department of Psychiatry, School of Medicine, University of Pittsburgh School of Social Work, Pittsburgh, PA, USA
| | - Rafael J Engel
- 2 University of Pittsburgh School of Social Work, Pittsburgh, PA, USA
| | | | - Ralph E Tarter
- 3 University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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25
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Szymczynska P, Walsh S, Greenberg L, Priebe S. Attrition in trials evaluating complex interventions for schizophrenia: Systematic review and meta-analysis. J Psychiatr Res 2017; 90:67-77. [PMID: 28231496 DOI: 10.1016/j.jpsychires.2017.02.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/27/2017] [Accepted: 02/08/2017] [Indexed: 11/18/2022]
Abstract
Essential criteria for the methodological quality and validity of randomized controlled trials are the drop-out rates from both the experimental intervention and the study as a whole. This systematic review and meta-analysis assessed these drop-out rates in non-pharmacological schizophrenia trials. A systematic literature search was used to identify relevant trials with ≥100 sample size and to extract the drop-out data. The rates of drop-out from the experimental intervention and study were calculated with meta-analysis of proportions. Meta-regression was applied to explore the association between the study and sample characteristics and the drop-out rates. 43 RCTs were found, with drop-out from intervention ranging from 0% to 63% and study drop-out ranging from 4% to 71%. Meta-analyses of proportions showed an overall drop-out rate of 14% (95% CI: 13-15%) at the experimental intervention level and 20% (95% CI: 17-24%) at the study level. Meta-regression showed that the active intervention drop-out rates were predicted by the number of intervention sessions. In non-pharmacological schizophrenia trials, drop-out rates of less than 20% can be achieved for both the study and the experimental intervention. A high heterogeneity of drop-out rates across studies shows that even lower rates are achievable.
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Affiliation(s)
- P Szymczynska
- Unit for Social and Community Psychiatry, Newham Centre for Mental Health, Queen Mary University of London, E13 8SP, UK.
| | - S Walsh
- Unit for Social and Community Psychiatry, Newham Centre for Mental Health, Queen Mary University of London, E13 8SP, UK
| | - L Greenberg
- Pragmatic Clinical Trials Unit, Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Yvonne Carter Building, 58 Turner Street, London E1 2AB, UK
| | - S Priebe
- Unit for Social and Community Psychiatry, Newham Centre for Mental Health, Queen Mary University of London, E13 8SP, UK
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Abstract
Medication nonadherence is common among patients with schizophrenia and due to a variety of factors including lack of insight, psychopathology, substance use disorder, issues associated with treatment, stigma, fragmentation of care, cultural influences, and socioeconomic status. Among this population, nonadherence is problematic because it can lead to decompensation or exacerbation of symptoms, relapse, rehospitalization or greater use of emergency psychiatric services, functional decline, and increased risk of death. Psychoeducational approaches alone are ineffective, but in combination with behavioral interventions, appear to be effective. Involving the patient's support system, in addition to other interventions, can improve treatment adherence. Many medication-related factors, such as effectiveness and tolerability of antipsychotics, regimen complexity, and past medication trials impact appropriate medication use. Therefore, optimizing the patient's pharmacotherapeutic regimens can improve adherence. Additional factors favorably influencing adherence include involving the patient in their treatment, fostering a therapeutic alliance, implementing/using reminder systems, and addressing substance use disorder. Medication nonadherence arises from multiple reasons that vary between patients. Thus, the most effective strategies to improve adherence are multifactorial and may involve both psychoeducational and behavioral techniques, as well as previously listed approaches. Strategies should be targeted toward the patient and their support system, whenever possible, to further improve the chances of appropriate medication use. Recognizing that all patients with schizophrenia are at risk for medication nonadherence is important. No one technique has been shown to be most effective; therefore, the risk for nonadherence should continually be assessed and multiple strategies should be targeted to the patient (and caregiver) and repeatedly implemented throughout the course of the patient's illness.
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Hamrin V, Sinclair VG, Gardner V. Theoretical Approaches to Enhancing Motivation for Adherence to Antidepressant Medications. Arch Psychiatr Nurs 2017; 31:223-230. [PMID: 28359437 DOI: 10.1016/j.apnu.2016.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/26/2016] [Accepted: 09/04/2016] [Indexed: 01/08/2023]
Abstract
PROBLEM Adherence to antidepressants is a major challenge in our health care system, with a high percentage of patients discontinuing their medications within six months. AIMS The purpose of this position paper is to discuss theoretical frameworks that address the psychological beliefs, benefits and barriers and feelings of autonomy that affect a person's willingness and motivation to take anti-depressant medications within a therapeutic relationship with a nurse practitioner. METHODS Three theoretical frameworks were selected to highlight particular perspectives relevant to enhancing patient motivation for medication adherence. The Self-Regulation Model, Health Belief Model, and Self-Determination Theory combined with motivational interviewing all offer guidance on strategies for improving adherence to antidepressants. CONCLUSIONS The Self-Regulation Model underscores the importance of illness representations that prompt considering patient perceptions of depression that affect adherence. The Health Belief Model focuses on cost-benefit considerations that affect patient's adherence, along with perceived control. Finally, Self-Determination Theory combined with motivational interviewing offers strategies that enhance autonomy and optimize collaboration and motivation for adherence. RELEVANCE FOR CLINICAL PRACTICE These three theoretical models are applied to a vignette for a patient who is having difficulty with adherence to antidepressant medication.
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28
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Dawson S, Lawn S, Simpson A, Muir-Cochrane E. Care planning for consumers on community treatment orders: an integrative literature review. BMC Psychiatry 2016; 16:394. [PMID: 27832769 PMCID: PMC5105250 DOI: 10.1186/s12888-016-1107-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 11/01/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Case management is the established model for care provision in mental health and is delivered within current care philosophies of person-centred and recovery-oriented care. The fact that people with a mental illness may be forced to receive care and treatment in the community poses challenges for clinicians aiming to engage in approaches that promote shared decision-making and self-determination. This review sought to gain an in-depth understanding of stakeholders' perspectives and experiences of care planning for consumers' on CTOs. METHODS An integrative review method allowed for inclusion of a broad range of studies from diverse empirical sources. Systematic searches were conducted across six databases. Following appraisal, findings from included papers were coded into groups and presented against a framework of case management. RESULTS Forty-eight papers were included in the review. Empirical studies came from seven countries, with the majority reporting on qualitative methods. Many similarities were reported across studies. Positive gains from CTOs were usually associated with the nature of support received, highlighting the importance of the therapeutic relationship in care planning. Key gaps in care planning included a lack of connection between CTO, treatment and consumer goals and lack of implementation of focussed interventions. CONCLUSIONS Current case management processes could be better utilised for consumers on CTOs, with exploration of how this could be achieved warranted. Workers need to be sensitive to the 'control and care' dynamic in the care planning relationship, with person-centred approaches requiring core and advanced practitioner and communication skills, including empathy and trust.
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Affiliation(s)
- Suzanne Dawson
- School of Nursing & Midwifery, Flinders University, GPO Box 2100, Adelaide, 5001, Australia.
| | - Sharon Lawn
- School of Medicine, Flinders University, Adelaide, Australia
| | - Alan Simpson
- School of Health Sciences, Nursing, City University London, London, UK
| | - Eimear Muir-Cochrane
- School of Nursing & Midwifery, Flinders University, GPO Box 2100, Adelaide, 5001, Australia
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29
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Hartung D, Low A, Jindai K, Mansoor D, Judge M, Mendelson A, Kansagara D, Motu Apuaka M, Freeman M, Kondo K. Interventions to Improve Pharmacological Adherence Among Adults With Psychotic Spectrum Disorders and Bipolar Disorder: A Systematic Review. PSYCHOSOMATICS 2016; 58:101-112. [PMID: 28139249 DOI: 10.1016/j.psym.2016.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/16/2016] [Accepted: 09/16/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND It is unclear as to which interventions are effective at improving medication adherence in individuals with serious and persistent mental illness. The goal of this systematic review is to synthesize evidence examining the effectiveness, harms, and costs of interventions to improve medication adherence in patients with psychotic spectrum disorders and bipolar disorder. METHODS We conducted a systematic search of several electronic databases through January 2015 using a structured search strategy. Studies were included if they involved adult patients in general mental health settings, reported both measures of medication adherence and clinical outcomes, and were of sufficient methodological rigor. Studies were quality assessed and synthesized using established methods. RESULTS We identified 24 studies that met inclusion criteria. Overall, 20 studies addressed interventions in patients with psychotic spectrum disorders. These interventions varied widely, with generally mixed findings contributing to low or insufficient strength of evidence; studies involving family members and technology interventions were the most consistently associated with a positive effect; however, the strength of the evidence was low because of intervention heterogeneity. The evidence was insufficient to determine the effectiveness of interventions in patients with bipolar disorder. CONCLUSIONS In individuals with psychotic spectrum disorders, interventions with family members or technology had the most consistent positive effect on adherence, although replication with objective adherence measures along with evaluation of harms and costs is needed. There was insufficient evidence to draw conclusions about interventions in individuals with bipolar disorder.
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Affiliation(s)
- Daniel Hartung
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR
| | - Allison Low
- VA Evidence-based Synthesis Program, Portland, OR
| | - Kazuaki Jindai
- VA Portland Health Care System, Portland, OR; Oregon Health & Science University, Portland, OR
| | - David Mansoor
- VA Portland Health Care System, Portland, OR; Oregon Health & Science University, Portland, OR
| | - Matthew Judge
- VA Portland Health Care System, Portland, OR; Oregon Health & Science University, Portland, OR
| | | | - Devan Kansagara
- VA Evidence-based Synthesis Program, Portland, OR; VA Portland Health Care System, Portland, OR; Oregon Health & Science University, Portland, OR
| | | | - Michele Freeman
- VA Evidence-based Synthesis Program, Portland, OR; Oregon Health & Science University, Portland, OR
| | - Karli Kondo
- VA Evidence-based Synthesis Program, Portland, OR; Oregon Health & Science University, Portland, OR.
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Abstract
Allergen immunotherapy (AIT) can improve allergic response by modifying the underlying disease. Many patients are nonadherent, and do not achieve full benefit. Numerous studies reveal that fewer than 10% of patients complete a full course and that most abandon treatment in the first year. The development and testing of interventions to improve AIT are emerging. Data from adherence interventions in other chronic conditions provide guidance to allergists/immunologists. Evidence-based communication strategies-patient-centered care, motivational interviewing, and shared-decision making-underscore the importance of taking time to establish trust, understand patient concerns and priorities, and involve the patient in decisions regarding AIT.
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31
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Cochran G, Hruschak V, DeFosse B, Hohmeier KC. Prescription opioid abuse: pharmacists' perspective and response. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2016; 5:65-73. [PMID: 29354541 PMCID: PMC5741039 DOI: 10.2147/iprp.s99539] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Opioid medication abuse and overdose are major concerns for public health, and a number of responses to address these issues have taken place across the US. Pharmacists and the pharmacy profession have made important contributions as a part of the response to this national crisis. This article provides a brief review of the antecedents, driving forces, and health status of patients involved in the opioid medication and overdose epidemic. This review further discusses pharmacy-based actions that have been undertaken to address this issue, including prescription drug monitoring, take-back, and naloxone training/distribution programs. This review likewise examines current efforts underway in the field to educate practitioners and needed future steps that must be taken by pharmacists in order to continue the profession's pivotal role in working toward resolving this national public health problem. In particular, evidence and arguments are presented for proactively identifying and intervening with patients who abuse and/or are at risk for overdose. Continued and active engagement by pharmacists in these efforts has the potential to result in important reductions in opioid medication abuse and overdose and improvements for patient's health.
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Affiliation(s)
- Gerald Cochran
- Department of Psychiatry, School of Medicine
- School of Social Work, University of Pittsburgh, Pittsburgh, PA
| | | | - Brooke DeFosse
- Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee, Memphis, TN, USA
| | - Kenneth C Hohmeier
- Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee, Memphis, TN, USA
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32
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Kreyenbuhl J, Record EJ, Himelhoch S, Charlotte M, Palmer-Bacon J, Dixon LB, Medoff DR, Li L. Development and Feasibility Testing of a Smartphone Intervention to Improve Adherence to Antipsychotic Medications. ACTA ACUST UNITED AC 2016; 12:152-167. [PMID: 27454213 DOI: 10.3371/csrp.krre.070816] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Approximately 60% of individuals with schizophrenia do not take their antipsychotic medications as prescribed, and nonadherence is associated with exacerbation of psychotic symptoms, increased hospital and emergency room use, and increased healthcare costs. Behavioral-tailoring strategies that incorporate medication taking into the daily routine and use environmental supports have shown promise as adherence-enhancing interventions. Informed by the Information-Motivation-Behavioral (IMB) Skills Model and using the iterative process of user-centered design, we collaborated with individuals with schizophrenia and psychiatrists to develop an interactive smartphone application and web-based clinician interface, MedActive, for improving adherence to oral antipsychotic treatment. MedActive facilitates the active involvement of individuals with schizophrenia in managing their antipsychotic medication regimen by providing automated reminders for medication administration and tailored motivational feedback to encourage adherence, and by displaying user-friendly results of daily ecological momentary assessments (EMAs) of medication adherence, positive psychotic symptoms, and medication side effects for individuals and their psychiatrists. In a 2-week open trial completed by 7 individuals with schizophrenia and their psychiatrists, MedActive was determined to be both feasible and acceptable, with patient participants responding to 80% of all scheduled EMAs and providing positive evaluations of their use of the application. Psychiatrist participants were interested in viewing the information provided on the MedActive clinician interface, but cited practical barriers to regularly accessing it and integrating into their daily practice.
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33
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Redefining Medication Adherence in the Treatment of Schizophrenia: How Current Approaches to Adherence Lead to Misinformation and Threaten Therapeutic Relationships. Psychiatr Clin North Am 2016; 39:199-216. [PMID: 27216900 DOI: 10.1016/j.psc.2016.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Medication adherence is as much of a problem today as it was 50 years ago. A major barrier to progress is that the definition emphasizes obedience to medication recommendations rather than shared outcome goals. As a result, schizophrenia patients are keenly aware of the social risks of disclosing nonadherence. Nondisclosure leads to misinformation, which in turn leads to serious errors in medication decisions. Another consequence is that adherence struggles may harm the therapeutic relationship. When nonadherence is inevitable, the strategy should shift to the use of harm reduction strategies that aim to preserve the therapeutic relationship while mitigating risks.
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34
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Fiszdon JM, Kurtz MM, Choi J, Bell MD, Martino S. Motivational Interviewing to Increase Cognitive Rehabilitation Adherence in Schizophrenia. Schizophr Bull 2016; 42:327-34. [PMID: 26420905 PMCID: PMC4753608 DOI: 10.1093/schbul/sbv143] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Adherence to treatment in psychiatric populations is notoriously low. In this randomized, controlled, proof-of-concept study, we sought to examine whether motivational interviewing (MI) could be used to enhance motivation for, adherence to, and benefit obtained from cognitive rehabilitation. Dual diagnosis MI, developed specifically for individuals with psychotic symptoms and disorganization, was further adapted to focus on cognitive impairments and their impact. Sixty-four outpatients diagnosed with schizophrenia spectrum disorders completed baseline assessments and were randomized to receive either the 2-session MI focused on cognitive functioning or a 2-session sham control interview focused on assessment and feedback about preferred learning styles. Next, all participants were given 4 weeks during which they could attend up to 10 sessions of a computer-based math training program, which served as a brief analog for a full course of cognitive rehabilitation. As hypothesized, MI condition was associated with greater increases in task-specific motivation along with greater training program session attendance. Moreover, postinterview motivation level predicted session attendance. There were no significant differences in improvement on a measure of cognitive training content, which may have been due to the abbreviated nature of the training. While the literature on the efficacy of MI for individuals with psychosis has been mixed, we speculate that our positive findings may have been influenced by the adaptations made to MI as well as the focus on a nonpharmacological intervention.
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Affiliation(s)
- Joanna M. Fiszdon
- Department of Psychology, VA Connecticut Healthcare System, West Haven, CT;,Department of Psychiatry, Yale University School of Medicine, New Haven, CT;,*To whom correspondence should be addressed; Psychology Service (116B), VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT 06516, US; tel: (203) 932-5711, ext. 2231, fax: (203) 937-3542, e-mail:
| | - Matthew M. Kurtz
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT;,Department of Psychology and Program in Neuroscience and Behavior, Wesleyan University, Middletown, CT
| | - Jimmy Choi
- Olin Neuropsychiatry Research Center, The Institute of Living, Hartford Hospital, Hartford, CT
| | - Morris D. Bell
- Department of Psychology, VA Connecticut Healthcare System, West Haven, CT;,Department of Psychiatry, Yale University School of Medicine, New Haven, CT
| | - Steve Martino
- Department of Psychology, VA Connecticut Healthcare System, West Haven, CT;,Department of Psychiatry, Yale University School of Medicine, New Haven, CT
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35
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Riegel B, Masterson Creber R, Hill J, Chittams J, Hoke L. Effectiveness of Motivational Interviewing in Decreasing Hospital Readmission in Adults With Heart Failure and Multimorbidity. Clin Nurs Res 2016; 25:362-77. [PMID: 26743119 DOI: 10.1177/1054773815623252] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Hospitalizations are common in heart failure (HF). Multimorbidity, defined as ≥2 comorbid conditions, drives many readmissions. The purpose of this pilot study was to test the effectiveness of motivational interviewing (MI) in decreasing these hospital readmissions. We enrolled 100 hospitalized HF patients into a randomized controlled trial, randomizing in a 2:1 ratio: intervention (n = 70) and control (n = 30). The intervention group received MI tailored to reports of self-care during one home visit and three to four follow-up phone calls. After 3 months, 34 participants had at least one hospital readmission. The proportion of patients readmitted for a condition unrelated to HF was lower in the intervention (7.1%) compared with the control group (30%, p = .003). Significant predictors of a non-HF readmission were intervention group, age, diabetes, and hemoglobin. Together, these variables explained 35% of the variance in multimorbidity readmissions. These preliminary results are promising in suggesting that MI may be an effective method of decreasing multimorbidity hospital readmissions in HF patients.
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Affiliation(s)
- Barbara Riegel
- University of Pennsylvania School of Nursing, Philadelphia, USA
| | | | - Julia Hill
- University of Pennsylvania School of Nursing, Philadelphia, USA
| | - Jesse Chittams
- University of Pennsylvania School of Nursing, Philadelphia, USA
| | - Linda Hoke
- Hospital of the University of Pennsylvania, Philadelphia, USA
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36
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Noordraven EL, Wierdsma AI, Blanken P, Bloemendaal AF, Mulder CL. Depot-medication compliance for patients with psychotic disorders: the importance of illness insight and treatment motivation. Neuropsychiatr Dis Treat 2016; 12:269-74. [PMID: 26893565 PMCID: PMC4745949 DOI: 10.2147/ndt.s97883] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Noncompliance is a major problem for patients with a psychotic disorder. Two important risk factors for noncompliance that have a severe negative impact on treatment outcomes are impaired illness insight and lack of motivation. Our cross-sectional study explored how they are related to each other and their compliance with depot medication. METHODS Interviews were conducted in 169 outpatients with a psychotic disorder taking depot medication. Four patient groups were defined based on low or high illness insight and on low or high motivation. The associations between depot-medication compliance, motivation, and insight were illustrated using generalized linear models. RESULTS Generalized linear model showed a significant interaction effect between motivation and insight. Patients with poor insight and high motivation for treatment were more compliant (94%) (95% confidence interval [CI]: 1.821, 3.489) with their depot medication than patients with poor insight and low motivation (61%) (95% CI: 0.288, 0.615). Patients with both insight and high motivation for treatment were less compliant (73%) (95% CI: 0.719, 1.315) than those with poor insight and high motivation. CONCLUSION Motivation for treatment was more strongly associated with depot-medication compliance than with illness insight. Being motivated to take medication, whether to get better or for other reasons, may be a more important factor than having illness insight in terms of improving depot-medication compliance. Possible implications for clinical practice are discussed.
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Affiliation(s)
- Ernst L Noordraven
- Dual Diagnosis Centre (CDP), Parnassia Psychiatric Institute, the Hague, the Netherlands; Department of Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - André I Wierdsma
- Department of Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Peter Blanken
- Parnassia Addiction Research Centre (PARC), Parnassia Psychiatric Institute, the Hague
| | - Anthony Ft Bloemendaal
- Dual Diagnosis Centre (CDP), Parnassia Psychiatric Institute, the Hague, the Netherlands
| | - Cornelis L Mulder
- Department of Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands; Bavo-Europoort Mental Health Care, Parnassia Psychiatric Institute, Rotterdam, the Netherlands
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37
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Abstract
Patient nonadherence significantly burdens the treatment of allergic rhinitis (AR). Fewer than half of prescribed doses of intranasal corticosteroid medication are taken. The challenges for immunotherapies are even greater. While sustained treatment for 3 to 5 years is required for full benefit, most patients receiving immunotherapy, either subcutaneous or sublingual, stop treatment within the first year. Although research into interventions to improve AR adherence is lacking, lessons learned from adherence interventions in other chronic health conditions can be applied to AR. Two well-established, overriding models of care-the chronic care model and patient-centered care-can improve adherence. The patient-centered care model includes important lessons for allergy providers in their daily practice, including understanding and targeting modifiable barriers to adherence. Additionally, recent studies have begun to leverage health information and communication technologies to reach out to patients and promote adherence, extending patient-centered interventions initiated by providers during office visits.
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Affiliation(s)
- Bruce G Bender
- Department of Pediatrics, National Jewish Health, 1400 Jackson Street, Denver, CO, 80206, USA,
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Abstract
This literature review addresses the question of whether motivational interviewing (MI) is effective at improving medication adherence in patients with schizophrenia. The databases PsycINFO, OVID Medline, and PubMed were searched using the keywords "schizophrenia," "medication adherence," and one of the following: "motivational interviewing," "adherence therapy," or "compliance therapy." Relevant studies from the last ten years were included, resulting in six studies being included in this literature review. One study presented evidence for a direct relationship between motivational interviewing and medication adherence. Most studies did not support this relationship. Some studies found evidence for a relationship between motivational interviewing and other outcomes such as improved psychotic symptoms and decreased re-hospitalization rates. Motivational interviewing may be beneficial for some patients with schizophrenia but should not be considered a first line therapy. Clinicians not already using motivational interviewing in providing care to their patients with schizophrenia should not implement it for this population.
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El-Mallakh P, Findlay J. Strategies to improve medication adherence in patients with schizophrenia: the role of support services. Neuropsychiatr Dis Treat 2015; 11:1077-90. [PMID: 25931823 PMCID: PMC4404876 DOI: 10.2147/ndt.s56107] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The purpose of this review is to describe research over the past 10 years on the role of support services in promoting medication adherence in mental health consumers diagnosed with schizophrenia. A literature search was conducted using the terms "medication adherence," "schizophrenia," and "support services," using Medline, PubMed, and CINAHL. Reference lists from published studies were also reviewed to identify additional research studies. Twenty-two articles focused on support-service intervention studies, and these were selected for review. Available support-service interventions include adherence therapy, electronic reminders via text messages and telephones, cognitive-behavioral and motivational strategies, and financial incentives. Support-service intervention strategies need to be tailored to the specific needs of mental health consumers with schizophrenia. More research is needed to investigate effective support services to enhance long-term adherence and adherence to medications for medical illnesses in this population.
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Affiliation(s)
| | - Jan Findlay
- College of Nursing, University of Kentucky, Lexington, KY, USA
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40
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Pladevall M, Divine G, Wells KE, Resnicow K, Williams LK. A randomized controlled trial to provide adherence information and motivational interviewing to improve diabetes and lipid control. DIABETES EDUCATOR 2014; 41:136-46. [PMID: 25486932 DOI: 10.1177/0145721714561031] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of this study was to assess whether providing medication adherence information with or without motivational interviewing improves diabetes and lipid control. METHODS Study participants were adult members of a health system in southeast Michigan, were using both oral diabetes and lipid-lowering medications, and had glycated hemoglobin (A1C) or low-density lipoprotein cholesterol (LDL-C) levels not at goal. Participants were randomly assigned to receive usual care (UC), n = 567; have medication adherence information (AI) provided to their physician, n = 569; or have AI and receive motivational interviewing (MI) though trained staff (AI + MI), n = 556. Primary outcomes were A1C and LDL-C levels at 18 months post randomization. RESULTS Primary outcomes were not significantly different between patients in the AI or AI + MI study arms when compared with UC. Similarly, neither oral diabetes nor lipid-lowering medication adherence was significantly different between groups. Patient participation in the AI + MI arm was low and limit the interpretation of the study results, but post hoc analysis of the AI + MI study arm showed that the number of MI sessions received was positively associated with only oral diabetes medication adherence. CONCLUSION Neither AI nor MI significantly improved diabetes and lipid control when compared with UC. Moreover, patient participation appeared to be a particular barrier for MI.
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Affiliation(s)
- Manel Pladevall
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan (Dr Pladevall, Dr Williams),Research Triangle Institute Health Solutions, Barcelona, Spain (Dr Pladevall)
| | - George Divine
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan (Dr Divine, Ms Wells)
| | - Karen E Wells
- Department of Public Health Sciences, Henry Ford Health System, Detroit, Michigan (Dr Divine, Ms Wells)
| | - Ken Resnicow
- Center for Health Communications Research, University of Michigan, Ann Arbor, Michigan (Dr Resnicow)
| | - L Keoki Williams
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan (Dr Pladevall, Dr Williams),Department of Internal Medicine, Henry Ford Health System, Detroit, Michigan (Dr Williams)
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