Factors that affect adherence to bipolar disorder treatments: a stated-preference approach

Investigating the ability to adhere to cardiometabolic medications with different properties: a retrospective cohort study of >500 000 patients in the USA

OBJECTIVE

Poor medication adherence remains highly prevalent and adversely affects health outcomes. Patients frequently describe properties of the pills themselves, like size and shape, as barriers, but this has not been evaluated objectively. We sought to determine the extent to which oral medication properties thought to be influential translate into lower objectively-measured adherence.

DESIGN

Retrospective cohort study.

SETTING

US nationwide commercial claims database, 2016-2019.

PARTICIPANTS

Among patients initiating first-line hypertension, diabetes or hyperlipidaemia treatment based on clinical guidelines, we measured pill size, shape, colour and flavouring, number of pills/day and fixed-dose combination status as properties.

OUTCOME MEASURES

Outcomes included discontinuation after the first fill (ie, never filling again over a minimum of 1-year follow-up) and long-term non-adherence (1-year proportion of days covered <0.80). We estimated associations between each property and outcomes, by therapeutic class (eg, statins), with multivariable logistic regression.

RESULTS

Across 604 323 patients, 14.6% discontinued after filling once (ie, were non-persistent), and 54.0% were non-adherent over 1-year follow-up. Large pill size was associated with non-adherence, except for thiazides (eg, metformin adjusted OR (aOR): 1.12, 95% CI: 1.06 to 1.18). Greater pill burden was associated with a higher risk of non-adherence across all classes (eg, metformin aOR: 1.58, 95% CI: 1.53 to 1.64 for two pills/day). Taking less than one pill/day was also associated with higher risk of non-adherence and non-persistence (eg, non-persistence statin aOR: 1.29, 95% CI: 1.20 to 1.38). Pill shape, colour, flavouring and combination status were associated with mixed effects across classes.

CONCLUSIONS

Pill burden and pill size are key properties affecting adherence for almost all classes; others, like size and combination, could modestly affect medication adherence. Clinical interventions could screen patients for potential intolerance to medication and potentially implement more convenient dosing schedules.

Prioritizing Treatment Goals of People Diagnosed with Bipolar I Disorder in the US: Best-Worst Scaling Results

Purpose

Bipolar I disorder (BP-I) is associated with significant disease burden, but evidence on treatment goals in people diagnosed with BP-I is scarce. This study sought to quantify treatment goals related to the pharmacological management of BP-I in adults in the US and to identify if subgroups of people with similar treatment goals exist.

Patients and Methods

A best-worst scaling (BWS) of treatment goals was developed based on available literature and input from experts and patients and was distributed as part of a survey between August and September 2021. Survey participants were adults with a self-reported diagnosis of BP-I who were recruited via an online panel in the US. Participants were asked to prioritize the importance of 16 treatment goals using BWS. BWS scores were computed using multinomial logistic regression, with the scores across all goals summing to 100 for each participant. Subgroups of people with similar preferences were identified using latent class analysis.

Results

The most important treatment goals for people diagnosed with BP-I (N=255) were "being less impulsive, angry, or irritable" (score: 9.73), or being "able to feel pleasure or happiness" (score: 9.54). Goals related to reducing the incidence of various potential adverse events of medication (scores: ≤4.51) or "reducing dependence on others" (score: 3.04) were less important. Two subgroups were identified. One subgroup (n=111) prioritized symptom-focused goals, considering "reducing frequency of mania, depression, and mixed episodes" and "being less impulsive, angry or irritable" the most important (scores: 12.46 and 11.85, respectively). The other subgroup (n=144) placed significantly more importance on social functioning-focused goals, including beginning or maintaining a relationship with a partner/significant other, and with family and/or friends (scores: 8.45 and 7.70, respectively).

Conclusion

People diagnosed with BP-I prioritized emotional improvements. Subgroups of people with BP-I prioritized either symptom-focused or social functioning-focused treatment goals.

Factors Associated with Long-term Medication Adherence in Patients Who Participated in a Short-term Group Psychoeducation Program for Bipolar Disorder

Improving adherence to medication and quality of life is a challenge in treating bipolar disorder. Therefore, psychoeducation plays an important role. This study examined factors associated with long-term medication adherence in patients with bipolar disorder who participated in a short-term psychoeducation program. Additionally, the relationships between medication adherence and medication attitudes and quality of life (QOL) were assessed. Multiple regression analysis was conducted on 67 inpatients and outpatients using medication adherence (Brief Evaluation for Medication Influences and Beliefs [BEMIB] score) as the dependent variable and clinical and demographic variables before and after the program as explanatory variables, one year after completion of the program. Pearson's correlation coefficients were calculated for associations between patients' BEMIB score and medication attitudes (Drug Attitude Inventory-10 [DAI-10]) and QOL (World Health Organization QOL-26 [WHOQOL-26] score) before and after the program and one year after program completion. The results showed that the CSQ-8 J (Client Satisfaction Questionnaire-8 Japanese) and DAI-10 scores immediately after the program were significantly related to the BEMIB score one year after program completion. Both the BEMIB and DAI-10 showed significant positive correlations with several items of the WHOQOL-26, both after the program and one year after completion of the program. The results suggest that medication attitudes acquired through psychoeducation and program satisfaction impact long-term medication adherence. The study also indicates that medication attitudes and medication adherence after a psychoeducation program are associated with QOL. Thus, patients' subjective views after a psychoeducation program can play an important role in long-term medication adherence and QOL.

Updated strategies for the management of poor medication adherence in patients with bipolar disorder

INTRODUCTION

Suboptimal adherence is a well-established, pervasive problem in individuals with bipolar disorder (BD) causing disability, suffering, and cost.

AREAS COVERED

This review covers new research since January 2016 regarding internal (patient-centered) and external (system level) barriers and facilitators to adherence. Measures of adherence, the efficacy of psychosocial adherence enhancement interventions in individuals with BD, and, finally, novel delivery systems for BD medication are also covered. Measures of adherence continue to fall broadly into objective measures (i.e. drug levels) and more subjective, self-report measures and a combination of these likely provides the most comprehensive picture. Efficacious components of psychosocial adherence enhancement interventions include psychoeducation, motivational interviewing, and cognitive behavioral strategies, yet methods for delivery vary. Long-acting injectable (LAI) medications for BD are the drug delivery system with the most promise for BD. Combining psychosocial components with novel drug delivery systems has the potential for establishing and maintaining medication adherence.

EXPERT OPINION

Psychosocial interventions improve adherence in individuals with BD. Psychoeducation is a necessary but not sufficient component in psychosocial interventions. LAIs should be considered earlier for adherence improvement than many treatment guidelines currently suggest. Comparative studies are lacking as is research into novel systems of medication delivery.

Fourteen-year trends in the prescribing patterns of pediatric bipolar patients discharged from two public mental hospitals in Taiwan

INTRODUCTION

The management of pediatric bipolar disorder (PBD) requires pharmacotherapy to control acute symptoms, reduce relapse, prevent suicide, and improve psychosocial functioning. The purpose of this study was to investigate prescribing patterns among PBD patients discharged from two public mental hospitals in Taiwan, from 2006 to 2019.

METHODS

PBD patients discharged from the two study hospitals, from 1 January 2006 to 31 December 2019 (n = 420), were included in the analysis. Prescribed drugs at discharge, including mood stabilizers (i.e., lithium, valproate, carbamazepine, and lamotrigine), antipsychotics (i.e., second- and first-generation antipsychotics, SGAs and FGAs), and antidepressants, were explored. Complex polypharmacy was defined as the use of 3 or more agents among the prescribed drugs. Time trends of each prescribing pattern were analyzed using the Cochran-Armitage Trend test.

RESULTS

The most commonly prescribed psychotropic agents were SGAs (76.0%), followed by valproate (65.7%) and FGAs (24.8%). The prescription rates of SGAs, antidepressants, antidepressant plus antipsychotic, and antidepressant without mood stabilizer significantly increased over time, whereas the prescription rates of mood stabilizers, lithium, and FGAs significantly decreased.

DISCUSSIONS

Prescribing patterns changed greatly for PBD patients over time. However, much more evidence supporting the effectiveness of psychotropic agents in PBD patients is required.

The problems and information needs of patients with bipolar disorder during the treatment process: A qualitative study in Turkey

The objective of the present study was to determine the problems and information needs of patients with bipolar disorder during the treatment process. The present research is in the type of descriptive and qualitative study. In-depth individual interviews were conducted with 11 volunteer patients with bipolar disorder. The data collected from the interviews were evaluated using the descriptive analysis method. In the study, four categories (disease onset/diagnosis stage, adherence to treatment, interpersonal relationships, information needs) and nine main themes (symptoms, family support, factors that positively affect treatment adherence, factors that negatively affect treatment adherence, positive effects of treatment, negative effects of treatment, stigmatization, treatment, disease) were determined. Patients with bipolar disorder can be helped to cope with the problems they experience by providing information about the disease, adherence to treatment, the treatment process, and the effects of drugs.

Psychiatric healthcare resource utilization following initiation of aripiprazole once-monthly: a retrospective real-world study

OBJECTIVES

This observational retrospective real-world study examined changes in healthcare resource utilization (HCRU) pre- and post-initiation of aripiprazole once-monthly (AOM 400) in patients with schizophrenia or bipolar I disorder.

METHODS

Electronic health record-derived, de-identified data from the NeuroBlu Database (2013-2020) were used to identify patients ≥18 years with schizophrenia (n = 222) or bipolar I disorder (n = 129) who were prescribed AOM 400, and had visit data within 3, 6, 9, or 12 months pre- and post-initial AOM 400 prescription. Rates of inpatient hospitalization, emergency department visits, inpatient readmissions, and average length of stay were examined and compared over 3, 6, 9, and 12 months pre-/post-AOM 400 using a McNemar test.

RESULTS

Statistically significant differences were seen in both schizophrenia and bipolar I disorder patient cohorts pre- and post-AOM 400 in inpatient hospitalization rates (p < .001 all time points, both cohorts) and 30-day readmission per patient rates (p < .001 all time points, both cohorts). Statistically significant improvement in mean length of stay was observed in both cohorts at all time points, except for at six months in patients with schizophrenia. Emergency department visit rates were significantly lower after AOM 400 initiation for both cohorts at all time points (p < .001).

CONCLUSIONS

A reduction in the rate of hospitalizations, emergency department visits, 30-day readmissions, and average length-of-stay was observed for patients diagnosed with either schizophrenia or bipolar I disorder, which suggests a positive effect of AOM 400 treatment on HCRU outcomes and is supportive of earlier analyses from different data sources.

The impact of antipsychotic adherence on acute care utilization

BACKGROUND

Non-adherence to psychotropic medications is common in schizophrenia and bipolar disorders (BDs) leading to adverse outcomes. We examined patterns of antipsychotic use in schizophrenia and BD and their impact on subsequent acute care utilization.

METHODS

We used electronic health record (EHR) data of 577 individuals with schizophrenia, 795 with BD, and 618 using antipsychotics without a diagnosis of either illness at two large health systems. We structured three antipsychotics exposure variables: the proportion of days covered (PDC) to measure adherence; medication switch as a new antipsychotic prescription that was different than the initial antipsychotic; and medication stoppage as the lack of an antipsychotic order or fill data in the EHR after the date when the previous supply would have been depleted. Outcome measures included the frequency of inpatient and emergency department (ED) visits up to 12 months after treatment initiation.

RESULTS

Approximately half of the study population were adherent to their antipsychotic medication (a PDC ≥ 0.80): 53.6% of those with schizophrenia, 52.4% of those with BD, and 50.3% of those without either diagnosis. Among schizophrenia patients, 22.5% switched medications and 15.1% stopped therapy. Switching and stopping occurred in 15.8% and 15.1% of BD patients and 7.4% and 20.1% of those without either diagnosis, respectively. Across the three cohorts, non-adherence, switching, and stopping therapy were all associated with increased acute care utilization, even after adjusting for baseline demographics, health insurance, past acute care utilization, and comorbidity.

CONCLUSION

Non-continuous antipsychotic use is common and associated with high acute care utilization.

The Role of Lifestyle on Adherence to Treatment in a Sample of Patients with Unipolar and Bipolar Depression

Introduction: Poor adherence to treatment is currently stated to be one of the causes of depression relapse and recurrence. The aim of the present study is to assess potential differences in terms of clinical and lifestyle features related to adherence to treatment in a sample of patients with unipolar and bipolar depression. Methods: One hundred and eight patients with a diagnosis of unipolar or bipolar depressive episode were recruited from January 2021 to October 2022. Adherence to psychopharmacological treatment was assessed using the clinician rating scale. Descriptive and association analyses were performed to compare subgroups based on adherence to treatment. Results: Lower levels of adherence to treatment were associated with fewer years of education, work impairment, manic prevalent polarity lifetime, and greater comorbidity with alcohol and drug abuse. The majority of patients with positive adherence did not report any hospitalization and involuntary commitment lifetime. Conclusions: Patients with a positive treatment adherence showed significant differences in terms of lifestyle and clinical features compared to non-adherent patients. Our results may help to identify patients more likely to have poor medication adherence, which seem to lead to a worse disease course and quality of life.

Impact of nurse-led medication adherence therapy on bipolar affective disorder: A randomized controlled trial

PURPOSE

This study evaluated the impact of nurse-led medication adherence therapy (MAT) on medication adherence behavior and symptom severity of inpatients with bipolar disorder.

METHOD

Two arms, single-blind, randomized controlled trial on individuals with bipolar disorder was conducted at inpatient department of mental healthcare setting, India. Eighty-five participants were randomly allocated to MAT group and Treatment as usual group. Standard measures were used to assess medication adherence and symptom severity of both groups at baseline and follow-up time points.

CONCLUSION

MAT improved medication adherence behavior resulting in marked decrease in symptom severity of participants with bipolar disorders.

IMPLICATIONS FOR NURSING PRACTICE

Psychiatric nurses can effectively implement MAT for bipolar inpatients, which improves better clinical outcomes, prevent relapse, and readmissions.

Evaluation of factors associated with medication adherence in patients with bipolar disorder using a medication event monitoring system: a 6-month follow-up prospective study

BACKGROUND

Non-adherence in patients with bipolar disorder (BD) results in symptoms, such as aggravation, BD recurrence, emergency room visits, re-hospitalization, and poor psychosocial outcomes. Though non-adherence rates have been reported to range between 30-50% in patients with BD, the problem of adherence is often either overlooked by the physician or denied by the patient. An essential first step to enhancing medication adherence is to objectively estimate adherence. The Medication Event Monitoring System (MEMS), which is a pill bottle cap with a microprocessor, is an accurate device for assessing medication adherence. Using the MEMS, we aimed to measure medication adherence in patients with BD and evaluate the factors associated with and 6-month changes in medication adherence.

METHODS

Participants with BD were recruited from the psychiatric outpatient clinic of the Korea University Guro Hospital. The medication adherence of each participant was assessed using the MEMS, a self-report, pill count, and clinician rating. MEMS-measured adherence was reassessed after 6 months. Patient demographics were recorded and clinical assessments were conducted. Data were analyzed using Kappa statistics and Pearson's correlation analysis.

RESULTS

Of the 59 participants, 50 records were included in the analysis. Patient adherence and adherence rate assessed by the MEMS were lower than those assessed by the other measures. MEMS-measured adherence was correlated more closely with pill counts than with self-reports or clinician ratings. MEMS-measured adherence was negatively associated with prescription duration and the Brief Psychiatric Rating Scale-Affect Subscale Score. Six-month changes in MEMS-measured adherence were positively associated with attitude toward drugs and negatively associated with weight gain assessed by the Udvalg for Kliniske Undersøgelser Side Effect Rating Scale.

CONCLUSIONS

Clinicians may have to consider the limited accuracy of self-reporting and clinician rating methods and exercise caution when assessing the medication adherence of patients with BD using these methods. Our findings may assist clinicians in the assessment and improvement of medication adherence in patients with BD and, consequently, may be useful for the treatment and prevention of BD recurrence.

Patient Medication Preferences for Managing Dry Eye Disease: The Importance of Medication Side Effects

Objectives

The side effects of dry eye medications can lead to medication non-adherence and, eventually, to poor outcomes. This study aimed to quantify to what extent the side effects of dry eye disease (DED) medications (burning/stinging sensation and blurring) are important to patients compared to medication benefits or costs.

Methods

Patients diagnosed with DED were recruited at a referral eye center in Singapore (n = 139). This study utilized a Discrete Choice Experiment where patients were presented with 10 choice tasks where they were asked to choose between their current medication (or no medication), and two hypothetical medications that varied based on five attributes: duration of burning/stinging, duration of blurring, time to medication effectiveness, medication frequency, and out-of-pocket cost. The main outcomes were relative attribute importance and predicted uptake.

Results

Latent class logistic regressions found two groups with distinct preferences. For both classes, duration of burning/stinging (Class 1 = 23%, Class 2 = 29%) and cost (Class 1 = 24%, Class 2 = 27%) were the most important attributes while duration of blurring (Class 1 = 15%, Class 2 = 9%) was the least important. The predicted uptake of a medication increased 18 percentage-points when burning/stinging duration decreased from 2 h to a few minutes. The predicted uptake for new medications was lowest for those on medication with well-controlled symptoms and highest for those who were not on medication and could not control their symptoms effectively.

Conclusion

This study showed that duration of burning/stinging was an important factor when choosing medications. Incorporating patient preferences in medication decisions can potentially improve patient acceptance of a treatment regimen.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-022-00586-8.

Systematic Review and Network Meta-analysis: Efficacy and Safety of Second-Generation Antipsychotics in Youths With Bipolar Depression

OBJECTIVE

To assess the relative efficacy and safety of second-generation antipsychotics for treating major depressive episodes in youths with bipolar disorder.

METHOD

A systematic literature review using PRISMA guidelines and network meta-analysis (NMA) of randomized controlled trials (RCTs) of second-generation antipsychotics for bipolar depression in youths 10 to 18 years of age was conducted. Efficacy measures included Children's Depression Rating Scale, Revised (CDRS-R) and Clinical Global Impressions-Bipolar Disorder-Severity Depression (CGI-BP-S-depression) and Overall (CGI-BP-S-overall) scores. Available safety outcomes included discontinuations (all-cause, lack of efficacy, adverse events), metabolic parameters (weight change, cholesterol, triglycerides, glucose), changes in prolactin, and somnolence. Results from the NMA were reported as mean changes from baseline or odds ratios (OR) with 95% credible intervals (CrIs).

RESULTS

Four RCTs comparing placebo to lurasidone, quetiapine (1 each for immediate- and extended-release), and the olanzapine-fluoxetine combination (OFC) met all of the inclusion criteria. Lurasidone and OFC demonstrated similar and statistically significant improvements in CDRS-R, but quetiapine did not (lurasidone: -5.70 [-8.66, -2.76]; OFC: -5.01 [-8.63, -1.38]; quetiapine: -1.85 [-5.99, 2.27]). Lurasidone was associated with smaller changes in weight, cholesterol, and triglycerides from baseline compared to OFC and quetiapine. There were no differences in changes in glucose levels among antipsychotics. In addition, lurasidone was associated with smaller change in prolactin levels compared to OFC but not quetiapine.

CONCLUSION

Evidence from 4 studies in this NMA indicated that lurasidone and OFC, but not quetiapine, were efficacious for the treatment of bipolar depression in youths. Lurasidone was associated with less weight gain and smaller impacts on cholesterol and triglycerides compared with quetiapine and OFC.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Genome-Wide Association Study of Lithium-Induced Dry Mouth in Bipolar I Disorder

Dry mouth is a rather common unpleasant adverse drug reaction (ADR) to lithium treatment in bipolar disorders that often lead to poor adherence or early dropout. The aim of this study was to identify the genetic variants of dry mouth associated with lithium treatment in patients with bipolar I (BPI) disorder. In total, 1242 BPI patients who had ever received lithium treatment were identified by the Taiwan Bipolar Consortium for this study. The proportions of patients who experienced impaired drug compliance during lithium medication were comparable between those only with dry mouth and those with any other ADR (86% and 93%, respectively). Dry mouth appeared to be the most prevalent (47.3%) ADR induced by lithium treatment. From the study patients, 921 were included in a genome-wide association study (GWAS), and replication was conducted in the remaining 321 patients. The SNP rs10135918, located in the immunoglobulin heavy chain locus (IGH), showed the strongest associations in the GWAS (p = 2.12 × 10⁻³⁷) and replication groups (p = 6.36 × 10⁻¹³) (dominant model) for dry mouth with a sensitivity of 84.9% in predicting dry mouth induced by lithium. Our results may be translated into clinical recommendation to help identify at-risk individuals for early identification and management of dry mouth, which will improve medication adherence.

Exploring patient experiences coping with using multiple medications: a qualitative interview study

OBJECTIVE

Long-term adherence to evidence-based medications in cardiometabolic diseases remains poor, despite extensive efforts to develop and test interventions and deploy clinician performance incentives. The limited success of interventions may be due to ignored factors such as patients' experience of medication-taking. Despite being potentially addressable by clinicians, these factors have not been sufficiently explored, which is particularly important as patients use increasing numbers of medications. The aim is to explore patient perspectives on medication-taking, medication properties that are barriers to adherence, and coping strategies for their medication regimen.

DESIGN

Individual, in-person, semistructured qualitative interviews.

SETTING

Urban healthcare system.

PARTICIPANTS

Twenty-six adults taking ≥2 oral medications for diabetes, hypertension or hyperlipidaemia with non-adherence. Interviews were digitally recorded and transcribed. Data were analysed using developed codes to generate themes. Representative quotations were selected to illustrate themes.

RESULTS

Participants' mean age was 55 years, 46% were female and 39% were non-white. Six key themes were identified: (1) medication-taking viewed as a highly inconvenient action (that patients struggle to remember to do); (2) negative implications because of inconvenience or illness perceptions; (3) actual medication regimens can deviate substantially from prescribed regimens; (4) certain medication properties (especially size and similar appearance with others) may contribute to adherence deviations; (5) development of numerous coping strategies to overcome barriers and (6) suggestions to make medication-taking easier (including reducing drug costs, simplifying regimen or dosing frequency and creating more palatable medications).

CONCLUSION

Patients with poor adherence often find taking prescription medications to be undesirable and take them differently than prescribed in part due to properties of the medications themselves and coping strategies they have developed to overcome medication-taking challenges. Interventions that reduce the inconvenience of medication use and tailor medications to individual needs may be a welcome development.

Does Cocaine Use Increase Medication Noncompliance in Bipolar Disorders? A United States Nationwide Inpatient Cross-Sectional Study

Introduction

Medication noncompliance among bipolar disorder (BD) is often linked with comorbid substance use disorders. This study aims to investigate cocaine use (CU) association with medication noncompliance in hospitalized BD patients.

Methods

Using data on 266,303 BD hospitalizations between 2010-2014 from the US Nationwide Inpatient Sample database, we obtained medication noncompliance rates stratified by demographics and cocaine use. Logistic regression was used to evaluate factors associated with medication noncompliance.

Results

Overall mean age, the prevalence of CU, and medication noncompliance were 41.58 (+0.11) years, 8.34%, and 16.08%, respectively. More than half of BD patients with comorbid CU were between 40-64 years (54.4%), while more male patients with BD were in the CU group (53.9%). With univariable logistic regression, CU (odds ratio [OR]: 1.77, 95% CI: 1.66-1.88) increased the odds of medication noncompliance among BD patients, and after adjusting for other variables there was sustained increased odds (adjusted odds ratio [aOR]: 1.40, 95% CI: 1.32-1.50).

Conclusion

This study showed that CU is associated with medication noncompliance among hospitalized BD patients. This highlights the importance of addressing CU among BD patients. Given the possible association of CU with medication noncompliance among BD patients, collaborative work between general adult psychiatry and addiction services is imperative in improving the management outcome of BD patients with comorbid CU.

Two randomized, double-blind, placebo-controlled trials and one open-label, long-term trial of brexpiprazole for the acute treatment of bipolar mania

BACKGROUND

Brexpiprazole is a dopamine/serotonin receptor partial agonist (D₂, 5-HT_1A) and antagonist (5-HT_2A) approved for treatment of schizophrenia and major depressive disorder (adjunct to antidepressants).

AIMS

This study aimed to investigate brexpiprazole as monotherapy in acute mania (bipolar I disorder) in two short-term (ST) studies (study 080 and study 081) and one open-label (OL) extension (study 083).

METHODS

ST studies were three-week randomized, double-blind, flexible dose (2-4 mg/day), placebo-controlled studies. The primary endpoint was mean change in Young Mania Rating Scale (YMRS) total score from baseline to day 21. The OL study was a 26-week flexible dose (2-4 mg/day) study for patients completing the ST studies.

RESULTS

A total of 164 and 158 (study 080) and 170 and 162 (study 081) inpatients with DSM-5 mania with/without mixed features were randomized to placebo or brexpiprazole, respectively. The primary analyses did not show a statistically significant difference between brexpiprazole and placebo: study 080: least squares mean difference (95% confidence limits): 0.14 (-1.74, 2.03), p = 0.8797; study 081: -1.62 (-3.56, 0.32), p = 0.1011. OL study patients (n = 381) demonstrated a gradual improvement in YMRS total score. Akathisia was the only adverse event, with an incidence of ⩾5% with brexpiprazole and more than placebo in the ST studies, or ⩾5% in the OL study. Brexpiprazole was more efficacious in patients with impaired or no insight (predominantly EU patients) than in patients with excellent insight (predominantly US patients).

CONCLUSIONS

Further studies are necessary to address the potential efficacy of brexpiprazole in acute mania, which should ensure that the study sample is severe enough (especially with regard to insight), and that the dose/titration schedule is not too modest.

Relation of medication adherence to cognitive functions in egyptian patients with bipolar I disorder

Nonadherence to medication regimens is frequently reported in bipolar I disorder (BDI) patients. However, little is known about the relationship between cognitive functions and adherence in BDI. To establish possible associations between medication adherence and cognitive function in patients with BDI. A total of 110 inpatients with BDI were subjected to the Structured Clinical Interview for DSM-IV Axis I Disorder, Morisky 8-Item Medication Adherence Scale, Young Mania Rating Scale, Wechsler Adult Intelligence Scale-Revised, Wechsler memory scale (WMS) and Wisconsin card sorting test (WCST). Patients were assessed on admission and followed up 6 months after discharge. Six months after discharge, (58.2%) of patients were nonadherent to their medications. The nonadherent group were younger males with less years of education, with lower mean scores in information orientation and visual memory backward domains of WMS and lower mean scores in perseveration responses, perseveration errors and learning to learn domains of WCST. In logistic regression analysis, younger age and impaired information orientation domain of WMS were putative predictors of nonadherence. Episodic memory and younger age were the strongest patients' related factors associated with nonadherence to medication. These results suggest that rehabilitation of specific cognitive skills may improve adherence in BDI.

Mapping modifiable determinants of medication adherence in bipolar disorder (BD) to the theoretical domains framework (TDF): a systematic review

BACKGROUND

Around 40% of people with bipolar disorder (BD) are non-adherent to medication leading to relapse, hospitalisation and increased suicide risk. Limited progress in addressing non-adherence may be partly attributable to insufficient understanding of the modifiable determinants of adherence that require targeting in interventions. We synthesised the modifiable determinants of adherence in BD and map them to the theoretical domains framework (TDF).

METHOD

We searched CINAHL, Cochrane Library, Embase, LILACS, Medline, PsychINFO and PubMed until February 2020. We included studies reporting modifiable determinants of adherence in BD. Two reviewers independently screened studies, assessed quality, extracted modifiable determinants and mapped them to TDF.

RESULTS

We included 57 studies involving 32 894 participants. Determinants reported by patients spanned 11 of the 14 TDF domains compared to six domains represented by clinician/researcher. The TDF domains most commonly represented (% and example) in studies were: 'Environmental context and resources' (63%, e.g. experiencing side effects), 'Beliefs about consequences' (63%, e.g. beliefs about medication effects), 'Knowledge' (40%, e.g. knowledge about disorder), 'Social influences' (33%, e.g. support from family/clinicians), 'Memory, attention and decision processes' (33%, e.g. forgetfulness), 'Emotion' (21%, e.g. fear of addiction) and 'Intentions' (21%, e.g. wanting alternative treatment). 'Intentions', 'Memory, attention and decision processes' and 'Emotion' domains were only reported by patients but not clinicians.

CONCLUSIONS

Clinicians may be underappreciating the full range of modifiable determinants of adherence and thus not providing adherence support reflective of patients' needs. Reporting of modifiable determinants in behavioural terms facilitates developing theory-based interventions to address non-adherence in BD.

Antipsychotic medication adherence and preventive diabetes screening in Medicaid enrollees with serious mental illness: an analysis of real-world administrative data

BACKGROUND

There is excess amenable mortality risk and evidence of healthcare quality deficits for persons with serious mental illness (SMI). We sought to identify sociodemographic and clinical characteristics associated with variations in two 2015 Healthcare Effectiveness Data and Information Set (HEDIS) measures, antipsychotic medication adherence and preventive diabetes screening, among Medicaid enrollees with serious mental illness (SMI).

METHODS

We retrospectively analyzed claims data from September 2014 to December 2015 from enrollees in a Medicaid specialty health plan in Florida. All plan enrollees had SMI; analyses included continuously enrolled adults with antipsychotic medication prescriptions and schizophrenia or bipolar disorder. Associations were identified using mixed effects logistic regression models.

RESULTS

Data for 5502 enrollees were analyzed. Substance use disorders, depression, and having both schizophrenia and bipolar disorder diagnoses were associated with both HEDIS measures but the direction of the associations differed; each was significantly associated with antipsychotic medication non-adherence (a marker of suboptimal care quality) but an increased likelihood of diabetes screening (a marker of quality care). Compared to whites, blacks and Hispanics had a significantly greater risk of medication non-adherence. Increasing age was significantly associated with increasing medication adherence, but the association between age and diabetes screening varied by sex. Other characteristics significantly associated with quality variations according to one or both measures were education (associated with antipsychotic medication adherence), urbanization (relative to urban locales, residing in suburban areas was associated with both adherence and diabetes screening), obesity (associated with both adherence and diabetes screening), language (non-English speakers had a greater likelihood of diabetes screening), and anxiety, asthma, and hypertension (each positively associated with diabetes screening).

CONCLUSIONS

The characteristics associated with variations in the quality of care provided to Medicaid enrollees with SMI as gauged by two HEDIS measures often differed, and at times associations were directionally opposite. The variations in the quality of healthcare received by persons with SMI that were identified in this study can guide quality improvement and delivery system reform efforts; however, given the sociodemographic and clinical characteristics' differing associations with different measures of care quality, multidimensional approaches are warranted.

Unfilled Prescriptions of Medicare Beneficiaries: Prevalence, Reasons, and Types of Medicines Prescribed

BACKGROUND

Despite the proven efficacy of prescription regimens in reducing disease symptoms and preventing or minimizing complications, poor medication adherence remains a significant public health problem. Medicare beneficiaries have high rates of chronic illness and prescription medication use, making this population particularly vulnerable to nonadherence. Failure to fill prescribed medication is a key component of nonadherence.

OBJECTIVES

To (1) determine the rates of self-reported failure to fill at least 1 prescription among a sample of Medicare beneficiaries in 2004, (2) identify the reasons for not filling prescribed medication, (3) examine the characteristics of Medicare beneficiaries who failed to fill their prescription(s), and (4) identify the types of medications that were not obtained.

METHODS

The study is a secondary analysis of the 2004 Medicare Current Beneficiary Survey (MCBS), an ongoing national panel survey conducted by the Centers for Medicare & Medicaid Services (CMS). Medicare beneficiaries living in the community (N = 14,464) were asked: "During the current year [2004], were there any medicines prescribed for you that you did not get (please include refills of earlier prescriptions as well as prescriptions that were written or phoned in by a doctor)?" Those who responded "yes" to this question (n = 664) were asked to identify the specific medication(s) not obtained. Rates of failure to fill were compared by demographic and income categories and for respondents with versus without self-reported chronic conditions, identified by asking respondents if they had ever been told by a doctor that they had the condition. Weighted population estimates for nonadherence were calculated using Professional Software for SUrvey DAta ANalysis for Multi-stage Sample Designs (SUDAAN) to account for the MCBS multistage stratified cluster sampling process. Unweighted counts of the prescriptions not filled by therapeutic class were calculated using Statistical Analysis Software (SAS).

RESULTS

In 2004, an estimated 1.6 million Medicare beneficiaries (4.4%) failed to fill or refill 1 or more prescriptions. The most common reasons cited for failure to fill were: "thought it would cost too much" (55.5%), followed by "medicine not covered by insurance" (20.2%), "didn't think medicine was necessary for the condition" (18.0%), and "was afraid of medicine reactions/contraindications" (11.8%). Rates of failure to fill were significantly higher among Medicare beneficiaries aged 18 to 64 years eligible through Social Security Disability Insurance (10.4%) than among beneficiaries aged 65 years or older (3.3%, P < 0.001). Rates were slightly higher for women than for men (5.0 vs. 3.6%, P = 0.001), for nonwhite than for white respondents (5.5% vs. 4.2%, P = 0.010), and for dually eligible Medicaid beneficiaries than for those who did not have Medicaid coverage (6.3% vs. 4.0% P = 0.001). Failure-to-fill rates were significantly higher among beneficiaries with psychiatric conditions (8.0%, P < 0.001); arthritis (5.2%, P < 0.001); cardiovascular disease (5.2%, P = 0.003); and emphysema, asthma, or chronic obstructive pulmonary disease (6.6%, P < 0.001) than among respondents who did not report those conditions, and the rate for respondents who reported no chronic conditions was 2.5%. Rates were higher for those with more self-reported chronic conditions (3.2%, 4.0%, 4.3%, and 5.9% for those with 1, 2, 3, and 4 or more conditions, respectively, P < 0.001). Among the prescriptions not filled (993 prescriptions indentified by 664 respondents), central nervous system agents, including nonsteroidal anti-inflammatory drugs, were most frequently identified (23.6%, n = 234), followed by cardiovascular agents (18.3%, n = 182) and endocrine/metabolic agents (6.5%, n = 65). Of the reported unfilled prescriptions, 8.1% were for antihyperlipidemic agents, 5.4% were for antidepressant drugs, 4.6% were for antibiotics, and 29.9% were for unidentified therapy classes.

CONCLUSION

Most Medicare beneficiaries fill their prescriptions, but some subpopulations are at significantly higher risk for nonadherence associated with unfilled prescriptions, including working-age beneficiaries, dual-eligible beneficiaries, and beneficiaries with multiple chronic conditions. Self-reported unfilled prescriptions included critical medications for treatment of acute and chronic disease, including antihyperlipidemic agents, antidepressants, and antibiotics.

DISCLOSURES

This study was funded by the U.S. Department of Education's National Institute on Disability and Rehabilitation Research, Field Initiated Research Grant H133G070055. However, the analysis and the interpretation of these findings do not necessarily represent the policy of the Department of Education and are not endorsed by the federal government. All authors contributed approximately equally to the study concept and design. Tuleu performed the majority of the data collection, with assistance from Kennedy. Kennedy interpreted the data, with assistance from Tuleu and Mackay. Kennedy and Mackay wrote the majority of the manuscript, with assistance from Tuleu. Kennedy made the majority of the changes in revision of the manuscript.

Antipsychotic treatment experiences of people with bipolar I disorder: patient perspectives from an online survey

BACKGROUND

Oral antipsychotic (AP) medications are frequently prescribed to people with bipolar I disorder (BD-I). A cross-sectional online survey examined the experiences of people living with BD-I with a history of recent AP use.

METHODS

Adults with self-reported physician-diagnosed BD-I (N = 200) who received oral APs during the prior year completed a survey on AP-related experiences, including side effects and their perceived burden on social functioning, adherence, and work. Items also assessed preferences for trade-offs (balancing symptom management and side effects) when considering a hypothetical new AP. The perceived impact of specific, prevalent side effects on adherence, work, and preferences for a hypothetical AP were also examined. Analyses were descriptive.

RESULTS

The survey sample had a mean age of 43.2 (SD = 12.4) years, was 60% female, and 31% nonwhite. Almost all participants (98%) had experienced AP side effects. Common self-reported side effects were feeling drowsy or tired (83%), lack of emotion (79%), anxiety (79%), dry mouth (76%), and weight gain (76%). Weight gain was cited as the most bothersome side effect, rated by most participants (68%) as "very" or "extremely bothersome." Nearly half of participants (49%) reported that AP side effects negatively impacted their job performance; almost all (92%) reported that side effects - most commonly anxiety and lack of emotion - negatively impacted social relationships (e.g., family or romantic partners). The most commonly-reported reason for stopping AP use was dislike of side effects (48%). Side effects most likely to lead to stopping or taking less of AP treatment included "feeling like a 'zombie'" (29%), feeling drowsy or tired (25%), and weight gain (24%). When considering a hypothetical new AP, the most common side effects participants wanted to avoid included AP-induced anxiety (50%), weight gain (48%), and "feeling like a 'zombie'" (47%).

CONCLUSIONS

Side effects of APs were both common and bothersome, and impacted social functioning, adherence, and work. Findings highlight the prevailing unmet need for new APs with more favorable benefit-risk profiles.

Patients' preferences for the treatment of anxiety and depressive disorders: a systematic review of discrete choice experiments

Introduction: Matching available mental health services to patients' preferences, as well as is possible, may increase patient satisfaction and help increase adherence to certain treatments. This study systematically reviewed discrete-choice experiments (DCEs) on patients' preferences for treatment of depressive and anxiety disorders and assessed the relative importance of outcome, process and cost attributes to improve the current and future treatment situations.Methods: A systematic literature review using PubMed, EMBASE and PsychInfo was conducted to retrieve all relevant DCEs published up to 15 April 2019, eliciting patient preferences for treatment of depressive and anxiety disorders. Data were extracted using an extraction sheet, and attributes were classified into outcome, process and cost attributes. The relative importance of each attribute category was then assessed, and studies were evaluated according to their reporting quality, using validated checklists.Results: A total of 11 studies were identified for qualitative analysis. All studies received an aggregate score of 4 on the five-point PREFS checklist (Purpose, Respondents, Explanation, Findings and Significance). Most attributes were outcome related (52%), followed by process (42%) and cost (6%) attributes. Comparing the attribute categories and summing up the relative importance weights for each category within the studies, process attributes were ranked as most important, followed by cost and outcome attributes.Conclusions: In this systematic review, heterogeneous results were observed regarding the inclusion and framing of different attributes across studies. Overall, patients considered process and cost attributes to be more important than outcome attributes. Outcomes and process are important for patients, and thus clinicians should be particularly aware of this and take patients' preferences into account, although the attribute importance may depend on chosen attributes and related levels.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Psycho-demographic and clinical predictors of medication adherence in patients with bipolar I disorder in a university hospital in Egypt

BACKGROUND

Poor adherence to treatment is one of the main challenges to symptom control and preventing recurrence in bipolar disorder (BD). Numerous studies have established an association between patients' poor adherence and an increased risk of recurrence, relapse of the symptoms and admission to hospital.

AIM

To study the socio-demographic and clinical factors associated with medication nonadherence in patients with BD who were admitted to the hospital.

SETTING

The study was conducted at the Institute of Psychiatry, Ain Shams University.

METHODS

A 1-year longitudinal prospective study of 110 patients, aged 18-60 years, with BD-I. Young Mania Rating Scale, Clinical Global Impression, Global Assessment of Functioning, Sheehan Disability Scale and Insight and Treatment Attitude Questionnaire were applied before and 6 months after discharge. Adherence was measured using the Morisky 8-Item Medication Adherence Scale. Sociodemographic data and level of functioning were studied in relation to adherence.

RESULTS

Higher adherence was noticed in female, married and older patients and those with a higher level of education. However, low adherence was more common in male, non-married and less educated patients. Follow-up after 6 months revealed that the high adherence group scored the lowest in terms of disability. Meanwhile, the low adherence group scored the highest scores in disability.

CONCLUSION

Several socio-demographic and clinical variables were found to be associated with a low adherence rate to the prescribed medication in patients with BD-I. Age and impaired insight were found to be significant predictive factors for non-adherence.

Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review and meta-analysis

BACKGROUND

Major psychiatric disorders are growing public health concern that attributed 14% of the global burden of diseases. The management of major psychiatric disorders is challenging mainly due to medication non-adherence. However, there is a paucity of summarized evidence on the prevalence of psychotropic medication non-adherence and associated factors. Therefore, we aimed to summarize existing primary studies' finding to determine the pooled prevalence and factors associated with psychotropic medication non-adherence.

METHODS

A total of 4504 studies written in English until December 31, 2017, were searched from the main databases (n = 3125) (PubMed (MEDLINE), Embase, CINAHL, PsycINFO, and Web of Science) and other relevant sources (mainly from Google Scholar, n = 1379). Study selection, screening, and data extraction were carried out independently by two authors. Observational studies that had been conducted among adult patients (18 years and older) with major psychiatric disorders were eligible for the selection process. Critical appraisal of the included studies was carried out using the Newcastle Ottawa Scale. Systematic synthesis of the studies was carried out to summarize factors associated with psychotropic medication non-adherence. Meta-analysis was carried using Stata 14. Random effects model was used to compute the pooled prevalence, and sub-group analysis at 95% confidence interval.

RESULTS

Forty-six studies were included in the systematic review. Of these, 35 studies (schizophrenia (n = 9), depressive (n = 16), and bipolar (n = 10) disorders) were included in the meta-analysis. Overall, 49% of major psychiatric disorder patients were non-adherent to their psychotropic medication. Of these, psychotropic medication non-adherence for schizophrenia, major depressive disorders, and bipolar disorders were 56%, 50%, and 44%, respectively. Individual patient's behaviors, lack of social support, clinical or treatment and illness-related, and health system factors influenced psychotropic medication non-adherence.

CONCLUSION

Psychotropic medication non-adherence was high. It was influenced by various factors operating at different levels. Therefore, comprehensive intervention strategies should be designed to address factors associated with psychotropic medication non-adherence.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017067436.

Factors Associated with Medication Adherence Among Patients with Severe Mental Disorders in China: A Propensity Score Matching Study

OBJECTIVE

The 686 project provides free essential drugs and follow-up for poor SMD patients, with the purpose of improving patients' medication adherence and reducing the occurrence of dangerous behaviors. The objective of this research was to determine the factors that influence medication adherence in patients with severe mental disorders (SMD) and analyze whether the 686 program significantly improved patient medication adherence.

METHODS

This study was conducted among SMD patients in 686 project and non-project SMD patients in the same community in 11 cities in Shandong Province of China. The data collected included basic patient information and disease treatment information. Medication adherence was divided into good adherence and poor adherence. Propensity score matching (1:1 match) was performed to adjust for differences in baseline characteristics.

RESULTS

One thousand two hundred ninety-two patients receiving free medication assistance policy (686 project group) and 1292 non-policy patients (control group) were analyzed. Patients who received the 686 project group had significantly better medication adherence than the non-policy group patients (92.6% vs.61.2%). Older age and consolidation period were associated with poor adherence, and education level was the positive determinant for adherence.

CONCLUSION

The 686 project could improve medication adherence to patients with SMD. Additional research will pay attention to medication adherence of patients who are elderly, in consolidation period and lower education levels. It should strengthen the guidance and supervision of patients' medication and strengthen the health education of family members and patients.

Lithium Treatment Over the Lifespan in Bipolar Disorders

Lithium has been the treatment of choice for patients with bipolar disorder (BD) for nearly 70 years. It is recommended by all relevant guidelines as a first-line treatment for maintenance therapy. In this review, we outline the current state of evidence for lithium in the treatment of BD over the lifespan. First, we summarize the evidence on efficacy in general, from relapse prevention to acute anti-manic treatment and its role in treating mood episodes with mixed features and bipolar depression. As patients are often treated for many years and different aspects have to be considered in different phases of life, we discuss the particularities of lithium in the treatment of paediatric BD, in older aged individuals and in pregnant women. Lastly, we discuss the evidence on lithium's proposed suicide-preventive effects, the dangers of rapid discontinuation and lithium's adverse effects, particularly with regard to long-term treatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A randomized controlled trial comparing lithium plus valproic acid versus lithium plus carbamazepine in young patients with type 1 bipolar disorder: the LICAVAL study

BACKGROUND

Treatment of bipolar disorder (BD) usually requires drug combinations. Combinations of lithium plus valproic acid (Li/VPA) and lithium plus carbamazepine (Li/CBZ) are used in clinical practice but were not previously compared in a head-to-head trial.

OBJECTIVE

The objective of this trial was to compare the efficacy and tolerability of Li/VPA versus Li/CBZ in treating type 1 BD in any phase of illness in young individuals.

METHODS

LICAVAL was a randomized, unicenter, open-label, parallel-group trial that was conducted from January 2009 to December 2012 in a tertiary hospital in São Paulo, Brazil. Participants were between 18 and 35 years old and were followed up for 2 years. Our primary outcome was the number of participants achieving/maintaining response and remission during the acute and maintenance phases of BD treatment, respectively. Other outcomes assessed were symptom severity and adverse events throughout the study. In the analysis of the primary outcome, we compared groups by using a two-way repeated measures analysis of variance and estimated effect sizes by using Cohen's d.

RESULTS

Of our 64 participants, 36 were allocated to Li/VPA and 28 to Li/CBZ. Our sample was composed predominantly of females (66.6%) and the average age was 27.8 years. A total of 27 (45.0%) participants had depression, 17 (28.3%) had mania/hypomania, and 16 (26.7%) had a mixed state. We found no between-group differences in CGI-BP (Clinical Global Impression Scale modified for use in bipolar disorder) scores (P = 0.326) or in any other outcome. Side effects differed significantly between groups only in the first week of treatment (P = 0.021), and there were more side effects in the Li/VPA group. Also, the Li/VPA group gained weight (+2.1 kg) whereas the Li/CBZ group presented slight weight loss (-0.2 kg).

CONCLUSION

Our study suggests that Li/VPA and Li/CBZ have similar efficacy and tolerability in BD but that Li/CBZ might have metabolic advantages in the long term.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00976794 . Registered on September 9, 2009.

Patient preferences for a guided self-help programme to prevent relapse in anxiety or depression: A discrete choice experiment

BACKGROUND

Anxiety and depressive disorders are increasingly being viewed as chronic conditions with fluctuating symptom levels. Relapse prevention programmes are needed to increase self-management and prevent relapse. Fine-tuning relapse prevention programmes to the needs of patients may increase uptake and effectiveness.

MATERIALS AND METHODS

A discrete choice experiment (DCE) was conducted amongst patients with a partially or fully remitted anxiety or depressive disorder. Patients were presented 20 choice tasks with two hypothetical treatment scenarios for relapse prevention, plus a "no treatment" option. Each treatment scenario was based on seven attributes of a hypothetical but realistic relapse prevention programme. Attributes considered professional contact frequency, treatment type, delivery mode, programme flexibility, a personal relapse prevention plan, time investment and effectiveness. Choice models were estimated to analyse the data.

RESULTS

A total of 109 patients with a partially or fully remitted anxiety or depressive disorder completed the DCE. Attributes with the strongest impact on choice were high effectiveness, regular contact with a professional, low time investment and the inclusion of a personal prevention plan. A high heterogeneity in preferences was observed, related to both clinical and demographic characteristics: for example, a higher number of previous treatment episodes was related to a preference for a higher frequency of contact with a professional, while younger age was related to a stronger preference for high effectiveness.

CONCLUSIONS

This study using a DCE provides insights into preferences for a relapse prevention programme for anxiety and depressive disorders that can be used to guide the development of such a programme.

Beyond cost-effectiveness: A five-step framework for appraising the value of health technologies in Asia-Pacific

Given resource constraints and the potential for increasingly high-cost, cost-effective medicines to become available, policymakers require strategies that go beyond cost-effectiveness when making resource allocation decisions. This manuscript presents a five-step framework that complements traditional health technology assessment (HTA) guidance documents that policymakers in Asia-Pacific and elsewhere may consider when setting up HTA guidelines and/or evaluating whether or not to subsidize a medicine or other health innovations. The framework recommends that subsidy decisions be based on five criteria: the relative burden of the condition as compared with other conditions (step 1), comparative and cost-effectiveness of the medicine (steps 2 and 3), the short-term impact on the budget (step 4), and other considerations including patient and societal preferences (step 5). Our approach, which is a complement to traditional HTA guidance documents, is not prescriptive but provides an evidence-based framework that HTA agencies in Asia-Pacific can follow as they aim to deliver value-based medicines to their constituents.

Reversibility of psychotropic medication induced weight gain among children and adolescents with bipolar disorders

OBJECTIVE

To assess the reversibility of weight gain associated with psychotropic medications in children.

METHODS

A retrospective cohort study was conducted using an ambulatory electronic medical records database. Individuals under 18 years of age were identified if they were initiating a new course of second generation/atypical antipsychotics (SGA) or mood stabilizers (MS) following a bipolar disorder diagnosis and subsequently discontinued treatment within 24 months of treatment initiation.

RESULTS

Of the 297 children who had experienced positive BMI percentile increase (mean±SD: 8.71±11.94) during the treatment of SGA and/or MS, treatment discontinuation led to an average of 1.88 (±13.41) unit decrease in BMI percentile during a 12-month period since the treatment discontinuation. Repeated measure mixed model analysis showed that the reduction of BMI percentile after treatment discontinuation was neither associated with the treatment regimens patients previously received, nor associated with time since the treatment discontinuation. The three statistically significant predictors were baseline BMI percentile, BMI percentile gained during the treatment, and comorbid substance abuse disorder.

CONCLUSION

Children with bipolar disorder were able to lose a fraction of weight gained during pharmacotherapy after the treatment discontinuation, however, their BMI percentile may not return to the prior treatment level within a year post-medication discontinuation.

Quantifying Social Reinforcement Among Family Members on Adherence to Medications for Chronic Conditions: a US-Based Retrospective Cohort Study

BACKGROUND

More than 50% of patients are non-adherent to medications, often without an easily identifiable reason to clinicians. No study has quantified the extent to which health behaviors like medication-taking are correlated within families using national or routinely collected data for a range of conditions.

OBJECTIVE

To examine how an individual's health behaviors are influenced by those of their family members, particularly in adherence to medications for chronic conditions.

DESIGN

Retrospective cohort study.

PATIENTS

Using claims from a large nationwide insurer, we identified patients initiating medications for one of five chronic conditions with a family member who also recently filled one of these medications.

MAIN MEASURES

The primary exposure was whether family members were fully adherent (defined as a proportion of days covered ≥ 80%) before the patient's date of initiation. The outcome of interest was whether patients were fully adherent in the 12 months after initiation. Baseline demographic and clinical characteristics were also measured before initiation. We used multivariable modified Poisson regression to examine the association between prior family adherence and subsequent patient adherence.

KEY RESULTS

Among 254,144 patients, rates of full adherence among patients whose family members were and were not fully adherent were 37.3% and 26.9%, respectively (adjusted relative risk [aRR] 1.29, 95%CI 1.28-1.31). The association was stronger when both used cardiometabolic medications (aRR 1.35, 95%CI 1.32-1.37). Similarly, patients were also 38% more likely to be adherent if they and their family members used a medication for the same condition (aRR 1.38, 95%CI 1.35-1.40).

CONCLUSIONS

Adherence among family members appeared to be highly correlated, suggesting positive reinforcement by family or the sharing of unmeasured behaviors or characteristics associated with better adherence. Regardless, information about prior adherence among family members from routinely collected data could potentially inform adherence prediction or intervention efforts.

Medication nonadherence in bipolar disorder: a narrative review

A number of effective maintenance medication options exist for bipolar disorder (BD) and these are regarded as the foundation of long-term treatment in BD. However, nonadherence to medication is common in BD. For example, a large data base study in the United States of America (USA) showed that approximately half of patients with BD were nonadherent with lithium and maintenance medications over a 12 month period. Such nonadherence carries a high risk of relapse due to the recurrent nature of the illness and the fact that abrupt cessation of treatment, particularly lithium, may cause rebound depression and mania. Indeed, medication nonadherence in BD is associated with significantly increased risks of relapse, recurrence, hospitalization and suicide attempts and a decreased likelihood of achieving remission and recovery, as well as with higher overall treatment costs. Factors associated with nonadherence include adverse effects of medication, complex medication regimens, negative patient attitudes to medication, poor insight, rapid-cycling BD, comorbid substance misuse and a poor therapeutic alliance. Clinicians should routinely enquire about nonadherence in a nonjudgmental fashion. Potential steps to improve adherence include simple pragmatic strategies related to prescribing including shared decision-making, psychoeducation with a clear focus on adherence, reminders (traditional and digital), potentially using a depot rather than an oral antipsychotic, managing comorbid substance misuse and improving therapeutic alliance. Financial incentives have been shown to improve adherence to depot antipsychotics, but this approach raises ethical issues and its long-term effectiveness is unknown. Often a combination of approaches will be required. The strategies that are adopted need to be patient specific, reflecting that nonadherence has no single cause, and chosen by the patient and clinician working together.

A Cross-sectional Analysis of Patterns and Predictors of Medication Adherence in Bipolar Disorder: Single Center Experience from South India

Objective

Our objective was to determine patterns and predictors of medication adherence in bipolar disorder.

Methods

Between August 2015 and December 2016, we recruited 160 patients with a diagnosis of bipolar disorder as per International Classification of Diseases-10: Clinical Descriptions and Diagnostic Guidelines. The diagnosis was further confirmed by using the MINI International Neuropsychiatric Inventory. All of them were currently in remission (confirmed by standard measures) and on stable dosing of medication for at least a year. Medication adherence was assessed using Tamil validated version of Morisky Medication Adherence Scale. Patients were dichotomized into low adherence (<6) and high adherence (≥6) groups and compared on various socio-demographic and clinical variables.

Results

Majority of the sample (n=97, 60.6%) demonstrated low adherence to treatment regimen. Being employed and having spent greater number of days in hospital were predictive of higher medication adherence (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.019-7.585; and OR 1.02, 95% CI 1.003-1.037, respectively). Fewer number of lifetime depressive episodes and positive drug attitudes demonstrated trend level positive association with high medication adherence.

Conclusion

Non-adherence to prescribed medications is a common problem in bipolar disorder. Interventions targeting vocation, medication focused psychoeducation and promotion of positive drug attitudes are likely to enhance medication adherence in this group.

Regularity of self-reported daily dosage of mood stabilizers and antipsychotics in patients with bipolar disorder

BACKGROUND

Polypharmacy is often prescribed for bipolar disorder, yet medication non-adherence remains a serious problem. This study investigated the regularity in the daily dosage taken of mood stabilizers and second generation antipsychotics.

METHODS

Daily self-reported data on medications taken and mood were available from 241 patients with a diagnosis of bipolar disorder who received treatment as usual. Patients who took the same mood stabilizer or second generation antipsychotic for ≥ 100 days were included. Approximate entropy was used to determine serial regularity in daily dosage taken. Generalized estimating equations were used to estimate if demographic or clinical variables were associated with regularity.

RESULTS

There were 422 analysis periods available from the 241 patients. Patients took drugs on 84.4% of days. Considerable irregularity was found, mostly due to single-day omissions and dosage changes. Drug holidays (missing 3 or more consecutive days) were found in 35.8% of the analysis periods. Irregularity was associated with an increasing total number of psychotropic drugs taken (p = 0.009), the pill burden (p = 0.026), and the percent of days depressed (p = 0.049).

CONCLUSION

Despite low missing percent of days, daily drug dosage may be irregular primarily due to single day omissions and dosage changes. Drug holidays are common. Physicians should expect to see partial adherence in clinical practice, especially with complex drug regimens. Daily dosage irregularity may impact the continuity of drug action, contribute to individual variation in treatment response, and needs further study.

Patient preferences for important attributes of bipolar depression treatments: a discrete choice experiment

PURPOSE

The purpose of this study was to assess patient preferences regarding pharmacological treatment attributes for bipolar depression using a discrete choice experiment (DCE).

METHODS

Adult members of an Internet survey panel with a self-reported diagnosis of bipolar depression were invited via e-mail to participate in a web-based DCE survey. Participants were asked to choose between hypothetical medication alternatives defined by attributes and levels that were varied systematically. The six treatment attributes included in the DCE were time to improvement, risk of becoming manic, weight gain, risk of sedation, increased blood sugar, and increased cholesterol. Attributes were supported by literature review, expert input, and results of focus groups with patients. Sawtooth CBC System for Choice-Based Conjoint Analysis was used to estimate the part-worth utilities for the DCE analyses.

RESULTS

The analytical sample included 185 participants (50.8% females) from a total of 200 participants. The DCE analyses found weight gain to be the most important treatment attribute (relative importance =49.6%), followed by risk of sedation (20.2%), risk of mania (13.0%), increased blood sugar (8.3%), increased cholesterol (5.2%), and time to improvement (3.7%).

CONCLUSION

Results from this DCE suggest that adults with bipolar depression considered risks of weight gain and sedation associated with pharmacotherapy as the most important attributes for the treatment of bipolar depression. Incorporating patient preferences in the treatment decision-making process may potentially have an impact on treatment adherence and satisfaction and, ultimately, patient outcomes.

Neuropsychological functioning, age, and medication adherence in bipolar disorder

Objectives

Poor adherence to medication is frequent in bipolar disorder (BD) and has been associated with several factors. To date, the relationship between low adherence and neuropsychological functioning in BD is still unclear. As age and neuropsychological functioning might have opposing influences on adherence, our aim was to investigate this link with a particular focus on the effect of age.

Methods

In a cross-sectional study, we included 353 patients divided into two age-groups (16–46; 47–71) from a French cohort diagnosed with BD (type I, II, NOS) and strictly euthymic. All patients had a standardized clinical and neuropsychological assessment and were categorized as high (n = 186) or low (n = 167) adherent based on their score from the Medication Adherence Rating Scale. Clinical information was collected based on a standardized interview and clinical validated scales. Neuropsychological performances were evaluated with an established standardized neuropsychological battery for bipolar disorder patients. After univariate analysis, neuropsychological and clinical predictors of low adherence were included in two age-specific stepwise multiple logistic regressions.

Results

A smaller number of hospitalizations (OR = 0.846, p = 0.012), a shorter illness duration (OR = 0.937, p = 0.003) and higher adverse effects (OR = 1.082, p<0.001) were associated with a greater risk of low adherence in the younger patients. In the older patients, low adherence was also predicted by a smaller number of hospitalizations (OR = 0.727, p = 0.008) and higher adverse effects (OR = 1.124, p = 0.005). Interestingly poor inhibition performance was also a significant predictor of low adherence in older patients (OR = 0.924, p = 0.030).

Conclusions

We found an age-specific relationship between cognitive functioning and adherence in patients with BD. Poor inhibition performances predicted low adherence in older patients only. Our results highlight the need to provide age-adapted therapeutic interventions to improve adherence in patients with BD.

Medication non-adherence in bipolar disorder: Review of rates, demographic and clinical predictors

AIM

To conduct a systematic search for all studies examining rates and demographic and illness-related determinants of medication non-adherence in bipolar disorder (BD).

METHODS

A comprehensive literature search was undertaken of six English-language databases to identify published articles on medication non-adherence in BD from inception till December 2016. Any article, either a review or an original-research article was examined for its relevance to the subject. All such articles were manually searched to locate any further articles containing relevant information. Studies were included only if they had adequately described the patient sample, assessment methods and statistical procedures, presented their results systematically and their conclusions were congruent with the results.

RESULTS

The initial search yielded 249 articles on the subject; of these 198 articles were included. Of the 162 original-research studies, 132 had provided information on rates of medication non-adherence in BD. There was a wide variation in rates ranging from universal adherence (100%) to almost universal non-adherence (96%); this discrepancy was more due to methodological differences than true variations in rates. Notwithstanding the significant discrepancies in methodology, based on these 132 studies mean rates of 41.5%-43% and median rates of 40%-41% were obtained for medication non-adherence in BD. Rates of adherence with mood stabilizers were significantly lower than those for antipsychotics, or for medications of all classes. None of the demographic attributes were unequivocally linked to medication non-adherence in BD. Similarly, medication-related variables such as type of medications, doses, treatment regimens and side effects did not demonstrate consistent associations with non-adherence. Among clinical characteristics the presence of comorbid substance use disorder and absence of insight were the only two factors clearly linked to non-adherence in BD.

CONCLUSION

Medication non-adherence is prevalent in about a third to half of patients with BD. Demographic, illness and treatment related factors do not predict non-adherence with certainty.

Adverse Drug Events in Patients with Mental Disorder in an Ambulatory Setting

Background:

Although adverse drug events (ADEs) among inpatients occur frequently and are widely studied, few data are available on ADEs among outpatients with mental disorders.

Aims:

To determine the rates, types, and severity of ADEs in patients with mental disorder.

Materials and Methods:

Cross-sectional survey of patients with mental disorder attending outpatient department. Data were collected over a period of 6 months.

Results:

A total of 400 patients (217 schizophrenia patients, 127 bipolar affective disorder patients, and 56 patients of depression) with a mean age of 32.1 ± 9.7(±standard deviation) participated in the study. Patients suffering from schizophrenia and all nonadherent patients reported significantly more ADEs (P < 0.05). Out of 343 patients (86%) who reported at least one ADE, majority (87%) reported central nervous system ADEs followed by weight gain (48%), gastro-intestinal (28%), skin (4%), cardiovascular (1%), and sexual dysfunctions (0.3%). Out of 673 ADEs reported, sedation (41%) and weight gain (25%) were reported most commonly. Most ADEs reported (76%) were mild; however, there were no life-threatening, fatal, or serious ADEs. The medication classes most frequently involved in ADEs were antipsychotics (72%) followed by sedatives (44%), antimanic drugs (32%), and antidepressants (27%). Patients on atypical antipsychotic drugs reported significantly more body weight gain (P < 0.05). More than three drugs were prescribed in 49% of patients who reported ADEs.

Conclusion:

The study data indicate high prevalence of ADEs in the outpatients on psychotropic medications.

Lithium and cognition in those with bipolar disorder

Although a percentage of patients report cognitive side-effects when taking lithium, it can be difficult to determine from the literature whether any cognitive changes reflect lithium itself, the lithium serum level, residual mood symptoms, the underlying nature of bipolar disorder, or biological alterations such as hypothyroidism. This review was carried out to synthesize and evaluate relevant literature examining any cognitive impact of lithium in those with bipolar disorder. The effect of lithium in those with bipolar disorder was examined across the cognitive domains of attention, psychomotor speed, processing speed, working memory, intellectual functioning, verbal memory, visual memory, and executive functioning by reviewing the published empirical literature. Any impact of hypothyroidism and lithium toxicity was also examined. The literature supports the conclusion that lithium has a distinct impact on psychomotor speed in participants with bipolar disorder. In contrast, there appears to be no impact on attention. Any impact of lithium on memory in patients with bipolar disorder is unclear as the literature is contradictory and any such effect may be overshadowed by the greater impact of residual mood symptoms. The impact on processing speed, intellectual abilities, and executive functioning also remains unclear. Several clinical management strategies are recommended.

Patient Preferences for Injectable Treatments for Multiple Sclerosis in the United States: A Discrete-Choice Experiment

Background and Objective

Patients’ perceptions and experiences of medication efficacy, medication adverse events, dosing frequency, and dosing complexity have been found to influence adherence to injectable disease-modifying treatments (DMTs) in patients with multiple sclerosis (MS). The aim of this study was to quantify patient preferences for features of injectable DMTs for MS.

Methods

Adult patients in the United States (US) with a self-reported diagnosis of MS completed an online discrete-choice experiment survey to assess preference for a number of features of a hypothetical injectable DMT. Patients chose hypothetical treatments in paired comparisons, where each treatment was described by features or attributes, including the number of years until disability progression, the number of relapses in the next 4 years, injection time, the frequency of injections, the occurrence of flu-like symptoms (FLS), and severity of injection-site reactions. Random-parameters logit regression parameters were used to calculate preference weights of attribute levels and the relative importance of changes in treatment features.

Results

Of the 205 patients who completed the survey, 192 provided sufficient data for analysis. The results indicated a broad range of tradeoffs that patients would be willing to make. With regard to this, the relative importance of an improvement in the number of years until disability progression from 1 to 2 (i.e., vertical distance between preference weights for these attribute levels) was 0.9 [95 % confidence interval (CI) 0.5–1.2], the relative importance of this change was approximately equivalent to that of an improvement from 12 injections per month to two (mean 0.8, 95 % CI 0.4–1.2), or approximately equivalent to a decrease from four to one relapses in the next 4 years (mean 0.8, 95 % CI 0.5–1.2), or FLS 3 days after every injection to 3 days after some injections (mean 1.0, 95 % CI 0.6–1.4).

Conclusions

These results suggest that an improvement in treatment efficacy may be as important as a reduction in injection frequency or a reduction in some adverse events for patients who self-administer injectable DMTs for MS. Understanding the preferences of patients who use injectable treatments will inform the development of such treatments, which may in turn improve patient medication adherence and well-being.

Electronic supplementary material

The online version of this article (doi:10.1007/s40271-015-0136-x) contains supplementary material, which is available to authorized users.

The Role of Qualitative Research Methods in Discrete Choice Experiments

Background. The use of qualitative research (QR) methods is recommended as good practice in discrete choice experiments (DCEs). This study investigated the use and reporting of QR to inform the design and/or interpretation of healthcare-related DCEs and explored the perceived usefulness of such methods. Methods. DCEs were identified from a systematic search of the MEDLINE database. Studies were classified by the quantity of QR reported (none, basic, or extensive). Authors (n = 91) of papers reporting the use of QR were invited to complete an online survey eliciting their views about using the methods. Results. A total of 254 healthcare DCEs were included in the review; of these, 111 (44%) did not report using any qualitative methods; 114 (45%) reported “basic” information; and 29 (11%) reported or cited “extensive” use of qualitative methods. Studies reporting the use of qualitative methods used them to select attributes and/or levels (n = 95; 66%) and/or pilot the DCE survey (n = 26; 18%). Popular qualitative methods included focus groups (n = 63; 44%) and interviews (n = 109; 76%). Forty-four studies (31%) reported the analytical approach, with content (n = 10; 7%) and framework analysis (n = 5; 4%) most commonly reported. The survey identified that all responding authors (n = 50; 100%) found that qualitative methods added value to their DCE study, but many (n = 22; 44%) reported that journals were uninterested in the reporting of QR results. Conclusions. Despite recommendations that QR methods be used alongside DCEs, the use of QR methods is not consistently reported. The lack of reporting risks the inference that QR methods are of little use in DCE research, contradicting practitioners’ assessments. Explicit guidelines would enable more clarity and consistency in reporting, and journals should facilitate such reporting via online supplementary materials.

Treatment-adherence in bipolar disorder: A patient-centred approach

About half of the patients diagnosed with bipolar disorder (BD) become non-adherent during long-term treatment, a rate largely similar to other chronic illnesses and one that has remained unchanged over the years. Non-adherence in BD is a complex phenomenon determined by a multitude of influences. However, there is considerable uncertainty about the key determinants of non-adherence in BD. Initial research on non-adherence in BD mostly limited itself to examining demographic, clinical and medication-related factors impacting adherence. However, because of inconsistent results and failure of these studies to address the complexities of adherence behaviour, demographic and illness-related factors were alone unable to explain or predict non-adherence in BD. This prompted a shift to a more patient-centred approach of viewing non-adherence. The central element of this approach includes an emphasis on patients’ decisions regarding their own treatment based on their personal beliefs, life circumstances and their perceptions of benefits and disadvantages of treatment. Patients’ decision-making processes are influenced by the nature of their relationship with clinicians and the health-care system and by people in their immediate environment. The primacy of the patient’s perspective on non-adherence is in keeping with the current theoretical models and concordance-based approaches to adherence behaviour in BD. Research over the past two decades has further endorsed the critical role of patients’ attitudes and beliefs regarding medications, the importance of a collaborative treatment-alliance, the influence of the family, and the significance of other patient-related factors such as knowledge, stigma, patient satisfaction and access to treatment in determining non-adherence in BD. Though simply moving from an illness-centred to a patient-centred approach is unlikely to solve the problem of non-adherence in BD, such an approach is more likely to lead to a better understanding of non-adherence and more likely to yield effective solutions to tackle this common and distressing problem afflicting patients with BD.

Medication Adherence in Patients with Bipolar Disorder: A Comprehensive Review

Poor medication adherence is a pervasive problem that causes disability and suffering as well as extensive financial costs among individuals with bipolar disorder (BD). Barriers to adherence are numerous and cross multiple levels, including factors related to bipolar pathology and those unique to an individual's circumstances. External factors, including treatment setting, healthcare system, and broader health policies, can also affect medication adherence in people with BD. Fortunately, advances in research have suggested avenues for improving adherence. A comprehensive review of adherence-enhancement interventions for the years 2005-2015 is included. Specific bipolar adherence-enhancement approaches that target knowledge gaps, cognitive patterns, specific barriers, and motivation may be helpful, as may approaches that capitalize on technology or novel drug-delivery systems. However, much work remains to optimally facilitate long-term medication adherence in people with BD. For adherence-enhancement approaches to be widely adapted, they need to be easily accessible, affordable, and practical.

Effects of switching to aripiprazole from current atypical antipsychotics on subsyndromal symptoms and tolerability in patients with bipolar disorder

We evaluated the effectiveness of aripiprazole among bipolar patients who had switched to this medication as a result of difficulty maintaining on their prestudy atypical antipsychotics (AAPs) because of subsyndromal mood symptoms or intolerance. This study included 77 bipolar patients who were in syndromal remission with an AAP as monotherapy or with an AAP combined with a mood stabilizer(s) who needed to switch from their present AAP because of subsyndromal symptoms or intolerance. At 24 weeks after switching to aripiprazole, the remission rates on the Montgomery-Åsberg Depression Rating Scale (MADRS) and on both the MADRS and the Young Mania Rating Scale were increased significantly in the full sample and in the inefficacy subgroup. In the inefficacy subgroup, the MADRS score change was significant during the 24 weeks of study. Total cholesterol and prolactin decreased significantly after switching to aripiprazole. The proportion of patients who had abnormal values for central obesity and hypercholesterolemia decreased significantly from baseline to week 24. These findings suggest that a change from the current AAP to aripiprazole was associated with improvement in subsyndromal mood symptoms and several lipid/metabolic or safety profile parameters in patients with bipolar disorder with tolerability concerns or subsyndromal mood symptoms.

Online information seeking by patients with bipolar disorder: results from an international multisite survey

Background

Information seeking is an important coping mechanism for dealing with chronic illness. Despite a growing number of mental health websites, there is little understanding of how patients with bipolar disorder use the Internet to seek information.

Methods

A 39 question, paper-based, anonymous survey, translated into 12 languages, was completed by 1222 patients in 17 countries as a convenience sample between March 2014 and January 2016. All patients had a diagnosis of bipolar disorder from a psychiatrist. Data were analyzed using descriptive statistics and generalized estimating equations to account for correlated data.

Results

976 (81 % of 1212 valid responses) of the patients used the Internet, and of these 750 (77 %) looked for information on bipolar disorder. When looking online for information, 89 % used a computer rather than a smartphone, and 79 % started with a general search engine. The primary reasons for searching were drug side effects (51 %), to learn anonymously (43 %), and for help coping (39 %). About 1/3 rated their search skills as expert, and 2/3 as basic or intermediate. 59 % preferred a website on mental illness and 33 % preferred Wikipedia. Only 20 % read or participated in online support groups. Most patients (62 %) searched a couple times a year. Online information seeking helped about 2/3 to cope (41 % of the entire sample). About 2/3 did not discuss Internet findings with their doctor.

Conclusion

Online information seeking helps many patients to cope although alternative information sources remain important. Most patients do not discuss Internet findings with their doctor, and concern remains about the quality of online information especially related to prescription drugs. Patients may not rate search skills accurately, and may not understand limitations of online privacy. More patient education about online information searching is needed and physicians should recommend a few high quality websites.

Electronic supplementary material

The online version of this article (doi:10.1186/s40345-016-0058-0) contains supplementary material, which is available to authorized users.