Concerns about medications mediate the association of posttraumatic stress disorder with adherence to medication in stroke survivors

Psychometric properties of the post-traumatic stress disorder checklist for DSM-5 (PCL-5) in Chinese stroke patients

BACKGROUND

Stroke is a devastating disease and can be sufficiently traumatic to induce post-traumatic stress disorder (PTSD). Post-stroke PTSD is attracting increasing attention, but there was no study assessing the psychometric properties of the PCL-5 in stroke populations. Our study was conducted to examine the psychometric properties of the PTSD Checklist for DSM-5 (PCL-5) in Chinese stroke patients.

METHODS

This was a cross-sectional observational study conducted at our hospital. Three hundred and forty-eight Chinese stroke patients came to our hospital for outpatient service were recruited. They were instructed to complete the PCL-5 scales and were interviewed for PTSD diagnosis with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5). The cutoff scores, reliability and validity of the PCL-5 were analyzed.

RESULTS

PCL-5 scores in our sample were positively skewed, suggesting low levels of PTSD symptoms. The reliability of PCL-5 was good. Exploratory and confirmatory factor analyses indicated acceptable construct validity, and confirmed the multi-dimensionality of the PCL-5. By CFA analysis, the seven-factor hybrid model demonstrated the best model fit. The PCL-5 also showed good convergent validity and discriminant validity. Receiver operating characteristic (ROC) analyses revealed a PCL-5 score of 37 achieved optimal sensitivity and specificity for detecting PTSD.

CONCLUSIONS

Our findings supported the use of PCL-5 as a psychometrically adequate measure of post-stroke PTSD in the Chinese patients.

Supportive psychological therapy can effectively treat post-stroke post-traumatic stress disorder at the early stage

Post-traumatic stress disorder (PTSD) can develop after stroke attacks, and its rate ranges from 4 to 37% in the stroke population. Suffering from PTSD not only decreases stroke patient’s quality of life, but also relates to their non-adherence of treatment. Since strokes often recur and progress, long-term medical management is especially important. However, previous studies generally focused on the epidemiological characteristics of post-stroke PTSD, while there are literally no studies on the psychological intervention. In our study, 170 patients with a first-ever stroke during the acute phase were recruited. They were randomized into Psycho-therapy group 1 and Control group 1, and were administered with preventive intervention for PTSD or routine health education, respectively. At 2-month follow-up, PTSD symptoms were evaluated. Participants who were diagnosed with post-stroke PTSD were further randomized into Psycho-therapy group 2 and Control group 2, and received supportive therapy or routine health counseling, respectively. At 6-month follow-up (1°month after the therapy was completed), PTSD symptoms were re-evaluated. Our results showed that at 2-month, the PTSD incidence in our series was 11.69%, and the severity of stroke was the only risk factor for PTSD development. The preventive intervention was not superior to routine health education for PTSD prevention. At 6-month, results indicated the supportive therapy did have a fine effect in ameliorating symptoms for diagnosed PTSD patients, superior to routine health counseling. Thus, our study was the first to provide evidence that the supportive therapy was effective in treating post-stroke PTSD early after its diagnosis. This clinical trial was preregistered on www.chictr.org.cn (ChiCTR2100048411).

Relationship of Societal Adaptation with Vaccine Worries among Healthcare Workers during the COVID-19 Pandemic: The Mediating Effects of Posttraumatic Stress Disorder

Vaccine hesitancy has become a major public health problem among healthcare workers (HCWs) in this coronavirus disease 2019 (COVID-19) pandemic. The aim of this study was to examine the relationship between societal adaptation and vaccine worries and the mediating effects of posttraumatic stress disorder (PTSD) indicators in HCWs. A total of 435 HCWs (327 women and 108 men) were recruited. Their levels of societal adaptation were evaluated using the Societal Influences Survey Questionnaire (SISQ). Their severity and frequency of PTSD symptoms were examined using the Disaster-Related Psychological Screening Test (DRPST). The severity of vaccine worries was assessed using the Vaccination Attitudes Examination (VAX) Scale. The relationships among societal adaptation, PTSD, and vaccine worries were examined using structural equation modeling. The severity of societal adaptation was positively associated with both the severity of PTSD and the severity of vaccine worries. In addition, the severity of PTSD indicators was positively associated with the severity of vaccine worries. These results demonstrated that the severity of societal adaptation was related to the severity of vaccine worries, either directly or indirectly. The indirect relationship was mediated by the severity of PTSD. Societal adaptation and PTSD should be taken into consideration by the community of professionals working on vaccine hesitancy. Early detection and intervention of PTSD should be the objectives for programs aiming to lower vaccine hesitancy among HCWs.

Contributing Factors and Induced Outcomes of Psychological Stress Response in Stroke Survivors: A Systematic Review

Background

Remarkable evidence indicates that psychological stress is significantly associated with stroke. However, a uniform recommendation to identify and alleviate poststroke psychological stress responses and improve postmorbid outcomes is not currently available. Thus, this systematic review aimed to summarize the types of poststroke psychological stress, measurement tools, contributing factors, and outcomes.

Methods

This systematic review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A literature search was conducted in PubMed, Web of Science, Embase, CNKI, WanFangData, and CQVIP from database inception to November 2021. Cross-sectional and longitudinal studies were included in this research. Quality assessment was performed based on the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

Results

Eighteen quantitative, peer-reviewed studies were included for analysis. Selected articles mainly investigated perceived stress and posttraumatic stress disorder after stroke. We classified the contributing factors into four categories: sociodemographic factors, clinical disease factors, psychological factors, and behavioral and lifestyle factors. The postmorbid outcomes were divided into three categories: clinical disease outcomes, psychological outcomes, and behavioral and quality of life outcomes.

Conclusions

Compared to common patients, stroke survivors with the following characteristics suffered an increased psychological stress response: younger age, the presence of caregivers, depression, unsuitable coping strategies, etc. Meanwhile, lower quality of life, worse drug compliance, worse functional independence, and more severe mental disorders were significantly associated with increased psychological stress symptoms. Further studies are required to provide more trustworthy and meaningful references for mitigating the damage caused by psychological stress after stroke.

Dyadic Disruption Theory

Aspects of couples' romantic relationships are some of the most powerful psychosocial forces shaping mental and physical health, but even high-quality relationships are not universally beneficial for patients. Dyadic health theories have largely focused on chronic illness management that occurs after the couple understands the disease and prognosis, rather than focusing on couples' interdependence in the days and weeks following a sudden and disruptive medical event (e.g., an acute coronary syndrome [ACS] or a stroke). To address this gap, I propose Dyadic Disruption Theory to guide research on couples' reactions to acute medical events and their consequences for individual and dyadic mental health, physical health, and behavior. I propose that dyadic processes of social support, shared reality, and co-rumination can precipitate harmful patient and partner dynamics when couples are distressed early post-event and offer three propositions that inform testable hypotheses. Finally, I discuss implications for early dyadic intervention and future directions for research.

The Role of Trauma in Mothers' COVID-19 Vaccine Beliefs and Intentions

OBJECTIVE

Research on COVID-19 vaccine beliefs has focused primarily on adults' intentions to vaccinate themselves; however, many parents will also face decisions about vaccinating their children. In this study, we examine how maternal posttraumatic stress disorder (PTSD) and trauma history relate to mothers' beliefs and intentions about the COVID-19 vaccine for themselves and their children.

METHODS

A total of 240 mothers with a mental health history participating in a parenting study answered online survey questions via Prolific. Questions assessed: (a) trauma indictors (past diagnosis, current symptoms, and lifetime exposure to events); (b) vaccine measures (intentions for self and child, COVID-19 vaccine confidence, general vaccine perceived safety, reasoning about vaccine intentions, sources of influence on intentions); and (c) possible explanatory variables (institutional distrust, negative worldviews). ANCOVAs and regression analyses were used.

RESULTS

When compared with mothers with other mental health diagnoses, mothers with a PTSD history had significantly less confidence in the COVID-19 vaccine and less intent to get the vaccine for themselves or their child. These effects were explained by greater institutional distrust (i.e., significant indirect effects). Mothers with a previous PTSD diagnosis also expressed different reasons for vaccine hesitancy (e.g., less belief in science) and ascribed less influence to healthcare and governmental sources in vaccine decision-making.

CONCLUSION

Findings highlight the potential utility of a trauma-informed approach in efforts to reduce COVID-19 vaccine hesitancy. For mothers with a history of PTSD, addressing institutional distrust, including towards the healthcare industry, may be an important element to consider in the content, delivery, and mode of vaccine messaging.

Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

OBJECTIVE

PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations.

METHODS

A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies.

RESULTS

From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.

Medications as Traumatic Reminders in Patients With Stroke/Transient Ischemic Attack-Induced Posttraumatic Stress Disorder

BACKGROUND AND PURPOSE

Posttraumatic stress disorder (PTSD) symptoms are common after stroke/transient ischemic attack (TIA) and have been associated with medication nonadherence, potentially because medications serve as traumatic reminders of the prior stroke/TIA. This study examined associations between stroke/TIA-induced PTSD and aversive cognitions toward preventive medications.

METHODS

We enrolled a cohort of patients presenting to the emergency department with suspected stroke/TIA. One month posthospitalization, we assessed PTSD symptoms specific to the index stroke/TIA using the PTSD checklist specific and asked patients how often (1) did thinking about your stroke medication make you feel nervous or anxious?; (2) did thinking about your stroke medication make you think about your risk for future strokes?; and (3) did you skip or avoid taking your stroke medication so you would not have to think about your stroke? Logistic regression models tested the association between PTSD symptoms and each aversive cognition, adjusting for age, sex, ethnicity, and depression.

RESULTS

Among 408 included patients, 11.0% had elevated PTSD symptoms. These patients were more likely to report that thinking about their stroke medication made them feel nervous or anxious (37.8% versus 9.9%, P<0.001) that thinking about their stroke medication made them think about their risk for future stroke/TIA (60.0% versus 24.0%, P<0.001), and that they skipped or avoided their stroke medication to not think about their prior stroke/TIA (11.1% versus 2.2%, P=0.009). In adjusted analyses, higher PTSD checklist specific scores were associated with increased nervousness/anxiety (odds ratio, 1.33 [95% CI, 1.18-1.50], P<0.001) and thoughts of future stroke (odds ratio, 1.27 [95% CI, 1.14-1.41], P<0.001), with a trend toward significance for skipping medications to avoid reminders of stroke (odds ratio, 1.20 [95% CI, 0.99-1.44], P=0.06).

CONCLUSIONS

Medications may serve as traumatic reminders after stroke/TIA-induced PTSD, potentially leading to medication nonadherence.

Stressing Out About the Heart: A Narrative Review of the Role of Psychological Stress in Acute Cardiovascular Events

OBJECTIVES

Survivors of acute cardiovascular disease (CVD) events, such as acute coronary syndrome (ACS) and stroke, may experience significant psychological distress during and following the acute event. Long-term adverse effects may follow, including the development of posttraumatic stress disorder (PTSD), increased overall all-cause mortality, and recurrent cardiac events. The goal of this concepts paper is to describe and summarize the rates of adverse psychological outcomes, such as PTSD, following cardiovascular emergencies, to review how these psychological factors are associated with increased risk of future events and long-term health and to provide a theoretical framework for future work.

METHODS

A panel of two board-certified emergency physicians, one with a doctorate in experimental psychology, along with one PhD clinical psychologist with expertise in psychoneuroendocrinology were co-authors involved in the paper. Each author used various search strategies (e.g., PubMed, Psycinfo, Cochrane, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors RESULTS: A meta-analysis of 24 studies (N > 2,300) found the prevalence of ACS-induced PTSD at nearly 12%, while a meta-analysis of nine studies (N = 1,138) found that 25% of survivors of transient ischemic attack and stroke report PTSD symptoms. The presence of PTSD doubles 3-year risk of CVD/mortality risk in ACS survivors. Cardiac patients treated during periods of ED overcrowding, hallway care, and perceived poor clinician-patient communication appear at greater risk for subsequent PTSD.

CONCLUSIONS

Psychological stress is often present in patients undergoing evaluation for acute CVD events. Understanding such associations provides a foundation to appreciate the potential contribution of psychological variables on acute and long-term cardiovascular recovery, while also stimulating future areas of research and discovery.

The Impact of Cardiac-induced Post-traumatic Stress Disorder Symptoms on Cardiovascular Outcomes: Design and Rationale of the Prospective Observational Reactions to Acute Care and Hospitalizations (ReACH) Study

Aims:

As many as 1 in 8 acute coronary syndrome (ACS) patients develop posttraumatic stress disorder (PTSD) due to the ACS, and ACS-induced PTSD may increase secondary cardiovascular disease (CVD) risk. However, prior studies have been small and underpowered to test plausible behavioral or biological mechanisms of the hypothesized PTSD-secondary CVD risk association. In this paper, we describe the design and methods of a large prospective observational cohort study to estimate the prognostic significance of ACS-induced PTSD, mechanisms for its association with CVD risk, and emergency department (ED) factors that may increase PTSD risk, in a cohort of patients evaluated for acute coronary syndrome (ACS) in the ED of a large, urban academic medical center.

Methods:

The Reactions to Acute Care and Hospitalization (ReACH) study follows 1,741 racially, ethnically, and socioeconomically diverse patients initially presenting to the ED with ACS symptoms. Psychosocial factors are assessed at baseline. Medication adherence is monitored by electronic pill bottle (eCAP). Participants are contacted by phone at 1-, 6-, and 12-months post-hospitalization to assess PTSD symptoms, hospital readmission, and recurrent CVD events/mortality (proactively searched and confirmed by medical records).

Conclusion:

This study will provide the most accurate estimates to date of PTSD’s association with recurrent CVD events and mortality and will test whether medication adherence mediates that association. Further, it will provide estimates of the contribution of ED and hospital factors to PTSD risk in ACS patients. If our hypotheses are supported, we will have identified PTSD as a novel target for secondary risk reduction.

Identifying targets for cardiovascular medication adherence interventions through latent class analysis

OBJECTIVE

Reasons for nonadherence to cardiovascular medications vary widely between individuals. Yet, adherence interventions are often uniformly applied, limiting their effectiveness. This study employed latent class analysis (LCA) to identify multidimensional profiles of reasons for nonadherence to cardiovascular medications.

METHOD

Participants (N = 137; MAge = 58.8, SDAge = 11.8) were drawn from an observational study of the impact of cardiac-induced posttraumatic stress disorder (PTSD) on cardiac medication adherence in patients presenting to the emergency department with a suspected acute coronary syndrome. Demographics and depressive symptoms were assessed at baseline. Extent of nonadherence to cardiovascular medications, reasons for nonadherence, and PTSD symptoms were assessed 1 month after discharge.

RESULTS

LCA identified 3 classes of reasons for medication nonadherence: capacity (related to routine or forgetting; approximately 45% of the sample), capacity + motivation (related to routine/forgetting plus informational or psychological barriers; approximately 14% of the sample), and no clear reasons (low probability of endorsing any items; approximately 41% of the sample). Participants reporting greater nonadherence were more likely to be in the capacity + motivation or no clear reasons classes compared with the capacity class. Participants endorsing higher PTSD severity were more likely to be in the capacity + motivation or capacity classes compared with the no clear reasons class.

CONCLUSIONS

Three distinct classes of reasons for nonadherence were identified, suggesting opportunities for tailored interventions: capacity, capacity + motivation, and no clear reasons. These preliminary findings, if replicated, could aid identification of patients at risk for greater extent of medication nonadherence and inform tailored interventions to improve adherence. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Development and Validation of a Measure to Assess Patients' Threat Perceptions in the Emergency Department

OBJECTIVE

Threat perceptions in the emergency department (ED; e.g., patients' subjective feelings of helplessness or lack of control) during evaluation for an acute coronary syndrome (ACS) are associated with the development of posttraumatic stress disorder (PTSD), and PTSD has been associated with medication nonadherence, cardiac event recurrence, and mortality. This study reports the development and validation of a seven-item measure of ED threat perceptions in English- and Spanish-speaking patients evaluated for ACS.

METHODS

Participants were drawn from an observational cohort study of 1,000 patients evaluated for ACS between 2013 and 2016 in a large New York City hospital. Participants reported on threat perceptions in the ED and during inpatient stay (using 12 items previously identified as predictive of PTSD) and reported on cardiac-induced PTSD 1 month postdischarge. Exploratory and confirmatory factor analyses were used to establish the factor structure and test measurement invariance. Validity and reliability were examined, as was the association of ED threat perceptions with cardiac-induced PTSD.

RESULTS

Factor analyses identified a seven-item measure of ED threat perceptions (e.g., "I feel helpless," "I am worried that I am going to die") for both English- and Spanish-speaking patients. ED threat perceptions demonstrated convergent validity, correlating with ED stress and ED crowdedness (r = 0.29 and r = 0.14), good internal consistency (α = 0.82), and stability (r = 0.61). Threat perceptions were associated with cardiac-induced acute stress at inpatient and PTSD symptoms at 1 month (r = 0.43 and r = 0.39).

CONCLUSIONS

This brief tool assessing ED threat perceptions has clinical utility for providers to identify patients at risk for developing cardiac-induced PTSD and is critical to inform research on whether threat may be modified in-ED to reduce PTSD incidence.

Posttraumatic stress disorder and nonadherence to medications prescribed for chronic medical conditions: A meta-analysis

BACKGROUND

Patients with posttraumatic stress disorder (PTSD) are at increased risk for adverse consequences from comorbid medical conditions. Nonadherence to medications prescribed to treat those comorbid conditions may help explain this increased risk. We sought to determine the association between PTSD and medication nonadherence and whether it varied according to the type of event inducing the PTSD.

METHODS

Prospective observational cohort or cross-sectional studies relating PTSD and nonadherence among adults prescribed medications for a chronic medical illness were identified by searching MEDLINE, EMBASE, PsycINFO, the Cochrane Library, CINAHL, SCOPUS, and the PILOTS Database and by hand-searching bibliographies from selected articles. Individual estimates of odds ratios were pooled using random effects meta-analysis with inverse variance weighting. Articles were pooled separately according to whether PTSD was induced by a medical versus non-medical event.

OUTCOMES

Sixteen articles comprising 4483 patients met eligibility criteria. The pooled effect size of the risk of PTSD to medication nonadherence was OR 1.22 (95% CI, 1.06-1.41). Among the 6 studies of medical event-induced PTSD, the OR was 2.08 (95% CI, 1.03-4.18); p = 0.04. Among the 8 studies in which PTSD was not induced by a medical event, the OR was 1.10 (95% CI, 0.99-1.24); p = 0.09.

INTERPRETATION

Patients with PTSD were more likely to be nonadherent to medications prescribed for chronic medical conditions - an association that may exist specifically when PTSD was induced by a medical event. Medications may serve as aversive reminders among survivors of acute medical events, magnifying avoidance behaviors characteristic of PTSD.

FUNDING

NHLBI.

Associations of depression, anxiety and PTSD with neurological disability and cognitive impairment in survivors of moyamoya disease

Depression, anxiety and posttraumatic stress disorder (PTSD) are common complications of cerebrovascular diseases. However, they were seldom explored in Moyamoya Disease (MMD) survivors. In this study, we measured the prevalence of depression, anxiety and PTSD in MMD survivors. We evaluated the association of mental disorders with neurological disability and cognitive impairment, and further find out the independent protective and risk factors of neurological disability and cognitive impairment. In MMD survivors, the prevalence of these three mental disorders is high, 46.7% for depression, 50% for anxiety and 47.5% for PTSD. Anxiety and PTSD were significantly associated with more severe neurological disability (p = 0.039 and < 0.001); depression and anxiety were significantly associated with greater cognitive deficiency (p = 0.004 and 0.002). We further found PTSD was the only risk factor associated with neurological disability, and the corresponding odds ratio (OR) and 95% confidence interval (CI) was 81.74 (9.91-674.17); depression and anxiety were risk factors associated with cognitive impairment, and the corresponding OR and 95%CI were 2.73 (1.10-6.81) and 3.37 (1.29-8.78). Therefore, these three mental disorders were associated with more severe neurological disability and greater cognitive deficiency in MMD survivors.

A systematic review of the inclusion of mechanisms of action in NIH-funded intervention trials to improve medication adherence

Medication nonadherence contributes to morbidity/mortality, but adherence interventions yield small and inconsistent effects. Understanding the mechanisms underlying initiation and maintenance of adherence could improve interventions. The National Institutes of Health (NIH) support adherence research, but it is unclear whether existing NIH-funded research incorporates mechanisms. We conducted a systematic review to determine the proportion of NIH-funded adherence trials that have tested hypothesized mechanisms of intervention effects. We included randomized and quasi-randomized NIH-funded trials with medication adherence in adults as the primary outcome. Studies were identified by searching electronic databases from inception to 6/2016, references, and clinicaltrials.gov. Two of 18 (11%) NIH-funded trials tested a hypothesized mechanism of an intervention's effect on medication adherence. Another 44 studies with medication adherence as a secondary outcome were described in protocol form, and are either ongoing or never published results, but none mentioned mechanism tests. Overall, 3% of NIH-funded trials with adherence as an outcome conducted, or plan to conduct, tests of behavior change mechanisms. These results mirror previous findings that very few studies of behavior change interventions actually test the mechanism by which the intervention is hypothesized to improve health behaviors. We must understand mechanisms if we are to improve the effectiveness of interventions.

Posttraumatic stress disorder due to acute cardiac events and aversive cognitions towards cardiovascular medications

Posttraumatic stress disorder (PTSD) after acute medical events is associated with medication nonadherence. The mechanisms of PTSD-related nonadherence are poorly understood. We tested whether patients with elevated PTSD symptoms induced by suspected acute coronary syndrome (ACS) were more likely to have aversive cognitions towards cardiovascular medications. We enrolled a consecutive cohort of patients who presented to the emergency department with suspected ACS. One month after discharge, ACS-induced PTSD symptoms were assessed using the PTSD Checklist (PCL-S), and patients were asked "how often did" (1) "you miss your heart medication because you did not want to be reminded about your heart problem"; (2) "thinking about your heart medication make you feel nervous or anxious"; and (3) "thinking about your heart medication make you think about your risk for future heart problems." Logistic regression was used to determine the association between elevated PTSD symptoms and each aversive cognition, adjusting for age, sex, race, ethnicity, education, depression, and ACS status. Of 424 patients included, 15.8% had elevated PTSD symptoms (PCL-S ≥ 34). In adjusted analyses, higher PCL-S scores were associated with missing medications to avoid reminders of heart disease (OR 1.22 per 5-point PCL-S increase, 95%CI 1.07-1.40), as well as anxiety (OR 1.34, 95%CI 1.19-1.51) and thoughts of future risk (OR 1.19, 95%CI 1.08-1.32) when thinking about cardiovascular medications. We concluded that patients with elevated PTSD symptoms following suspected ACS were more likely to report aversive cognitions about their cardiovascular medications, suggesting that medications can act as traumatic reminders of the cardiac event and ongoing risk in this group.

Psychological Determinants of Medication Adherence in Stroke Survivors: a Systematic Review of Observational Studies

BACKGROUND

Medications targeting stroke risk factors have shown good efficacy, yet adherence is suboptimal. To improve adherence, its determinants must be understood. To date, no systematic review has mapped identified determinants into the Theoretical Domains Framework (TDF) in order to establish a more complete understanding of medication adherence.

PURPOSE

The aim of this study was to identify psychological determinants that most influence stroke survivors' medication adherence.

METHODS

In line with the prospectively registered protocol (PROSPERO CRD42015016222), five electronic databases were searched (1953-2015). Hand searches of included full text references were undertaken. Two reviewers conducted screening, data extraction and quality assessment. Determinants were mapped into the TDF.

RESULTS

Of 32,825 articles, 12 fulfilled selection criteria (N = 43,984 stroke survivors). Tested determinants mapped into 8/14 TDF domains. Studies were too heterogeneous for meta-analysis. Three TDF domains appeared most influential. Negative emotions ('Emotions' domain) such as anxiety and concerns about medications ('Beliefs about Consequences' domain) were associated with reduced adherence. Increased adherence was associated with better knowledge of medications ('Knowledge' domain) and stronger beliefs about medication necessity ('Beliefs about Consequences' domain). Study quality varied, often lacking information on sample size calculations.

CONCLUSIONS

This review provides foundations for evidence-based intervention design by establishing psychological determinants most influential in stroke survivors' medication adherence. Six TDF domains do not appear to have been tested, possibly representing gaps in research design. Future research should standardise and clearly report determinant and medication adherence measurement to facilitate meta-analysis. The range of determinants explored should be broadened to enable more complete understanding of stroke survivors' medication adherence.

A systematic review of the inclusion of mechanisms of action in NIH-funded intervention trials to improve medication adherence

Medication nonadherence contributes to morbidity/mortality, but adherence interventions yield small and inconsistent effects. Understanding the mechanisms underlying initiation and maintenance of adherence could improve interventions. The National Institutes of Health (NIH) support adherence research, but it is unclear whether existing NIH-funded research incorporates mechanisms. We conducted a systematic review to determine the proportion of NIH-funded adherence trials that have tested hypothesized mechanisms of intervention effects. We included randomized and quasi-randomized NIH-funded trials with medication adherence in adults as the primary outcome. Studies were identified by searching electronic databases from inception to 6/2016, references, and clinicaltrials.gov. Two of 18 (11%) NIH-funded trials tested a hypothesized mechanism of an intervention's effect on medication adherence. Another 44 studies with medication adherence as a secondary outcome were described in protocol form, and are either ongoing or never published results, but none mentioned mechanism tests. Overall, 3% of NIH-funded trials with adherence as an outcome conducted, or plan to conduct, tests of behavior change mechanisms. These results mirror previous findings that very few studies of behavior change interventions actually test the mechanism by which the intervention is hypothesized to improve health behaviors. We must understand mechanisms if we are to improve the effectiveness of interventions.

Enduring somatic threat perceptions and post-traumatic stress disorder symptoms in survivors of cardiac events

Post-traumatic stress disorder due to acute cardiovascular events may be uniquely defined by enduring perceptions of somatic threat. We tested whether post-traumatic stress disorder at 1 month post-acute coronary syndrome indeed required both high peritraumatic threat during the acute coronary syndrome and ongoing cardiac threat perceptions. We assessed peritraumatic threat during emergency department enrollment of 284 patients with a provisional acute coronary syndrome diagnosis and cardiac threat perceptions and post-traumatic stress disorder symptoms 1 month post-discharge. In a multiple regression model with adjustment for important covariates, emergency department threat perceptions were associated with higher 1 month post-traumatic stress disorder symptoms only among those with high levels of ongoing cardiac threat.

Adherence to Antihypertensive Therapy

Adherence to antihypertensive medication remains a key modifiable factor in the management of hypertension. The multidimensional nature of adherence and blood pressure (BP) control call for multicomponent, patient-centered interventions to improve adherence. Promising strategies to improve antihypertensive medication adherence and BP control include regimen simplification, reduction of out-of-pocket costs, use of allied health professionals for intervention delivery, and self-monitoring of BP. Research to understand the effects of technology-mediated interventions, mechanisms underlying adherence behavior, and sex-race differences in determinants of low adherence and intervention effectiveness may enhance patient-specific approaches to improve adherence and disease control.

Predictive factors of non-adherence to secondary preventative medication after stroke or transient ischaemic attack: A systematic review and meta-analyses

Purpose

Non-adherence to secondary preventative medications after stroke is relatively common and associated with poorer outcomes. Non-adherence can be due to a number of patient, disease, medication or institutional factors. The aim of this review was to identify factors associated with non-adherence after stroke.

Method

We performed a systematic review and meta-analysis of studies reporting factors associated with medication adherence after stroke. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL and Web of Knowledge. We followed PRISMA guidance. We assessed risk of bias of included studies using a pre-specified tool based on Cochrane guidance and the Newcastle–Ottawa scales. Where data allowed, we evaluated summary prevalence of non-adherence and association of factors commonly reported with medication adherence in included studies using random-effects model meta-analysis.

Findings

From 12,237 titles, we included 29 studies in our review. These included 69,137 patients. The majority of included studies (27/29) were considered to be at high risk of bias mainly due to performance bias. Non-adherence rate to secondary preventative medication reported by included studies was 30.9% (95% CI 26.8%–35.3%). Although many factors were reported as related to adherence in individual studies, on meta-analysis, absent history of atrial fibrillation (OR 1.02, 95% CI 0.72–1.5), disability (OR 1.27, 95% CI 0.93–1.72), polypharmacy (OR 1.29, 95% CI 0.9–1.9) and age (OR 1.04, 95% CI 0.96–1.14) were not associated with adherence.

Discussion

This review identified many factors related to adherence to preventative medications after stroke of which many are modifiable. Commonly reported factors included concerns about treatment, lack of support with medication intake, polypharmacy, increased disability and having more severe stroke.

Conclusion

Understanding factors associated with medication taking could inform strategies to improve adherence. Further research should assess whether interventions to promote adherence also improve outcomes.

An Enduring Somatic Threat Model of Posttraumatic Stress Disorder Due to Acute Life-Threatening Medical Events

Posttraumatic stress disorder (PTSD) occurs in 12-25% of survivors of acute life-threatening medical events such as heart attack, stroke, and cancer, and is associated with recurrence of cardiac events and mortality in heart attack survivors. This article reviews the current state of knowledge about PTSD after such events, and proposes an Enduring Somatic Threat (EST) model of PTSD due to acute life-threatening medical events to address underappreciated differences between PTSD due to past, discrete/external traumatic events (such as combat) and PTSD due to acute manifestations of chronic disease that are enduring/internal in nature (such as heart attack and stroke). The differences include the external versus internal/somatic source of the threat, the past versus present/future temporal focus of threatening cognitions, the different types and consequences of avoidance behavior, and the different character and consequences of hyperarousal. Although important differences between the two types of PTSD exist, the EST model proposes that the underlying fear of mortality maintains PTSD symptoms due to both discrete/external and ongoing/somatic events. Finally, this article offers a research agenda for testing the EST model, with a particular focus on areas that may improve cardiovascular prognosis and health behaviors in survivors of heart attack and stroke.

Understanding patients' adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the Necessity-Concerns Framework

BACKGROUND

Patients' beliefs about treatment influence treatment engagement and adherence. The Necessity-Concerns Framework postulates that adherence is influenced by implicit judgements of personal need for the treatment (necessity beliefs) and concerns about the potential adverse consequences of taking it.

OBJECTIVE

To assess the utility of the NCF in explaining nonadherence to prescribed medicines.

DATA SOURCES

We searched EMBASE, Medline, PsycInfo, CDSR/DARE/CCT and CINAHL from January 1999 to April 2013 and handsearched reference sections from relevant articles.

STUDY ELIGIBILITY CRITERIA

Studies using the Beliefs about Medicines Questionnaire (BMQ) to examine perceptions of personal necessity for medication and concerns about potential adverse effects, in relation to a measure of adherence to medication.

PARTICIPANTS

Patients with long-term conditions.

STUDY APPRAISAL AND SYNTHESIS METHODS

Systematic review and meta-analysis of methodological quality was assessed by two independent reviewers. We pooled odds ratios for adherence using random effects models.

RESULTS

We identified 3777 studies, of which 94 (N = 25,072) fulfilled the inclusion criteria. Across studies, higher adherence was associated with stronger perceptions of necessity of treatment, OR = 1.742, 95% CI [1.569, 1.934], p<0.0001, and fewer Concerns about treatment, OR = 0.504, 95% CI: [0.450, 0.564], p<0.0001. These relationships remained significant when data were stratified by study size, the country in which the research was conducted and the type of adherence measure used.

LIMITATIONS

Few prospective longitudinal studies using objective adherence measures were identified.

CONCLUSIONS

The Necessity-Concerns Framework is a useful conceptual model for understanding patients' perspectives on prescribed medicines. Taking account of patients' necessity beliefs and concerns could enhance the quality of prescribing by helping clinicians to engage patients in treatment decisions and support optimal adherence to appropriate prescriptions.

Predictors of long-term adherence to evidence-based cardiovascular disease medications in outpatients with stable atherothrombotic disease: findings from the REACH Registry

BACKGROUND

Despite overall improvements in cardiovascular-disease therapies and outcomes, medication nonadherence remains an important barrier to effective secondary prevention of atherothrombotic disease.

HYPOTHESIS

Long-term medication adherence in outpatients with stable atherothrombotic disease is impacted by demographic and clinical factors.

METHODS

We examined data from the prospective international Reduction of Atherothrombosis for Continued Health (REACH) Registry. Analyses were derived from 25 737 patients with established atherothrombotic disease with complete adherence data at enrollment and at year 4. Adherence was defined as patients' self-report of taking medications based on class I American College of Cardiology/American Heart Association guidelines for secondary prevention as defined, including antiplatelet agents, statins, and antihypertensive medications.

RESULTS

Among patients with atherothrombotic disease, 12 500 (48.6%) were deemed adherent to guideline-recommended medications. Adherent patients were younger, white, and had less polyvascular disease. Hispanic and East Asian patients were less likely to be adherent as compared with white patients (odds ratio [OR]: 0.72, 95% confidence interval [CI]: 0.59-0.88; and OR: 0.67, 95% CI: 0.53-0.83, respectively). Patients who had a nonfatal MI or underwent coronary angioplasty/stenting during follow-up were more likely to be adherent compared with patients without these events (OR: 1.73, 95% CI: 1.25-2.38; and OR: 2.15, 95% CI: 1.72-2.67, respectively). On the other hand, nonfatal stroke during follow-up was inversely associated with adherence (OR: 0.77, 95% CI: 0.61-0.97).

CONCLUSIONS

Using a large international registry of outpatients with atherothrombotic disease, we found that age, region, race/ethnicity, and incident cardiovascular events were predictive of long-term guideline adherence for secondary prevention, suggesting that certain patient groups may benefit from targeted interventions to improve adherence.

Correlates of post-traumatic stress disorder in stroke survivors

BACKGROUND

Post-traumatic stress disorder (PTSD) can occur after life-threatening events, including illness, but correlates of PTSD after stroke or transient ischemic attack (TIA) have not been well described.

METHODS

We measured the prevalence of stroke-induced PTSD with the PTSD Checklist Specific for stroke (PCL-S) in adults who had a stroke or TIA within 5 years. A PCL-S score of 50 or more indicated likely PTSD. We tested for potential predictors of stroke-associated PTSD, including demographics, stroke history, disability, medical comorbidities, depression, and emotional support and then examined the association between poststroke PTSD and measures of physical and mental health.

RESULTS

Of 535 participants, 95 (18%) had a PCL-S score of 50 or more; the mean score was 35.4 ± 13.7 (range 17-80 of 85). In logistic regression analysis, low income (odds ratio [OR] 1.98, 95% confidence interval [CI] 1.01-3.61), recurrent stroke or TIA (OR 1.86, 1.10-3.16), more disability (OR 1.79, 1.43-2.23), and increased comorbidities (OR 1.90, 1.05-3.45) were independently associated with PTSD. Older age (OR .93, .90-.95), marriage or partnership (OR .52, .28-.98), and having emotional support (OR .25, .11-.54) were protective against developing PTSD. Participants with likely PTSD had worse physical and mental health.

CONCLUSIONS

In this racially and ethnically diverse cohort of stroke and TIA survivors, stroke-induced PTSD was associated with younger age, recurrent strokes, greater disability, and comorbidities. PTSD was associated with a substantially increased physical, mental, and quality of life burden in this already vulnerable population. Having social support was protective, suggesting a potential target for intervention.

A systematic review investigating fatigue, psychological and cognitive impairment following TIA and minor stroke: protocol paper

BACKGROUND

Approximately 20,000 people have a transient ischemic attack (TIA) and 23,375 have a minor stroke in England each year. Fatigue, psychological and cognitive impairments are well documented post-stroke. Evidence suggests that TIA and minor stroke patients also experience these impairments; however, they are not routinely offered relevant treatment. This systematic review aims to: (1) establish the prevalence of fatigue, anxiety, depression, post-traumatic stress disorder (PTSD) and cognitive impairment following TIA and minor stroke and to investigate the temporal course of these impairments; (2) explore impact on quality of life (QoL), change in emotions and return to work; (3) identify where further research is required and to potentially inform an intervention study.

METHODS/DESIGN

A systematic review of MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane libraries and grey literature between January 1993 and April 2013 will be undertaken. Two reviewers will conduct screening search results, study selection, data extraction and quality assessment. Studies of adult TIA and minor stroke participants containing any of the outcomes of interest; fatigue, anxiety, depression, PTSD or cognitive impairment will be included. Studies at any time period after TIA/minor stroke, including those with any length of follow-up, will be included to investigate the temporal course of impairments. QoL, change in emotions and return to work will also be documented. The proportion of TIA or minor stroke participants experiencing each outcome will be reported.If appropriate, a meta-analysis will pool results of individual outcomes. Studies will be grouped and analyzed according to their follow-up timeframe into short-term (< 3 months after TIA/minor stroke), medium-term (3 to 12 months) and long term (> 12 months). Sub-analysis of studies with a suitable control group will be conducted. Exploratory sub-analysis of memory and attention domains of cognitive impairment will be conducted.

DISCUSSION

The current treatment goal for TIA and minor stroke patients is secondary stroke prevention. If these patients do experience fatigue, psychological or cognitive impairments then this treatment alone is unlikely to be sufficient. The results of this comprehensive review will increase understanding of treatment needs for this patient group, identify where further research is required and potentially inform an intervention trial.

Medication nonadherence and psychiatry

PURPOSE OF REVIEW

Nonadherence to appropriately prescribed medication for psychiatric disorders prevents patients from realizing the full benefits of their treatment and negatively impacts on individuals, their families and the healthcare system. Understanding and reducing nonadherence is therefore a key challenge to quality care for patients with psychiatric disorders. This review highlights findings regarding the prevalence and consequence of nonadherence, barriers to adherence and new intervention methods from 2012 onwards.

RECENT FINDINGS

Recent research has highlighted that nonadherence is a global challenge for psychiatry and has linked nonadherence to poorer outcomes, including hospital admissions, suicide and mortality. Optimizing medication regimens can reduce nonadherence; however, often a complex interplay of factors affects individuals' motivation and ability to follow their prescription. Psychiatrists can enable patients to develop an accurate model of their illness and treatment and facilitate adherence. However, nonadherence is often a hidden issue within consultations. Novel interventions using new technologies and tailoring techniques may have the potential to reduce nonadherence.

SUMMARY

Nonadherence remains a significant challenge for patients with psychiatric disorders, physicians and healthcare systems. New developments demonstrate the importance of developing tailored interventions to enable patients to overcome perceptual and practical barriers to adherence.