Adherence to medication in bipolar disorder: a qualitative study exploring the role of patients' beliefs about the condition and its treatment

Aripiprazole/Sertraline Combination: Clinical and Cost-Effectiveness in Comparison With Quetiapine for the Treatment of Bipolar Depression (ASCEnD Trial)-Protocol for a Nested Qualitative Study

INTRODUCTION

Bipolar disorder is a recurrent mental health disorder with a prevalence rate of 1.4%. On average, there can be a delay of 9.5 years from the initial presentation of symptoms to a confirmed diagnosis. Individuals living with bipolar disorder have a reduced life expectancy. There is limited evidence regarding the effectiveness of antidepressants in treating bipolar disorder. The ASCEnD clinical trial will test the clinical and cost-effectiveness of the aripiprazole/sertraline combination in comparison with quetiapine for the treatment of bipolar depression (individuals who suffer from depressive episodes in bipolar disorder) and will include a nested qualitative study.

METHODS

The qualitative study will use semi-structured interviews to explore pilot trial participants' and clinicians' perspectives on recruitment procedures, the acceptability of the intervention, the management of bipolar disorder and attitudes to medication combinations.

CONCLUSION

Findings will inform recruitment strategies and optimise training for the participating sites in the ASCEnD full trial. They will also help to illuminate the lived experience of people with bipolar disorder and the clinicians who work with people with bipolar disorder. The discussion will explore perspectives on the delay in diagnosis, having a diagnosis, the impact of living with bipolar disorder and attitudes to treatment, including drug combinations.

PATIENT OR PUBLIC CONTRIBUTION

A Lived Experience Advisory Panel (LEAP) has been convened with the support of the McPin Foundation, which will contribute to the ASCEnD trial and its nested qualitative study to provide input on the design and delivery of the trial and qualitative study, analysis of qualitative data and dissemination of findings.

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

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

"What makes you well?" Supports of well-being in bipolar disorder. A qualitative study

OBJECTIVE

Subjective experience of people living with bipolar disorder is gaining attention in the field of research. Improving well-being could be as important as symptom remission, but this constitutes a vague concept. This study aimed at exploring the boundaries and the determinants of the well-being of people living with bipolar disorder in a French context.

METHODS

Individual semi-structured interviews were conducted with 16 patients by three professionals. Interviews were transcribed and analysed using the thematic analysis method.

RESULTS

Various dimensions emerged as contributing to well-being: daily routines, connectedness, regaining a positive identity, and self-awareness for self-management.

CONCLUSIONS

In addition to those common to the general population, this study highlighted specific determinants of well-being: the construction of a positive identity through acceptance of the diagnosis, the importance of self-awareness and self-management. They are highly intertwined with those of personal recovery and could help caregivers design interventions that directly target these goals. This study aimed to identify specific components of well-being for people living with bipolar disorder. Understanding the determinants of well-being enable caregivers to design tailored interventions that directly target quality of life and help improve bipolar disorder outcomes.

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.

Exploring mental health clients' current medication knowledge, beliefs and experience with healthcare providers in the community in South Australia

In Australia, mental illness has been recognised as a National Health Priority area, with the coronavirus pandemic adding a layer of urgency to the need to address the multiple health problems faced by clients with mental illnesses. Whilst much has been done in efforts to support these clients, little is known about their medication knowledge and experience with health professionals. The aim of the study was to explore the knowledge and beliefs of clients on the use of psychotropic medications and study their experiences with healthcare providers. Adult participants at a not-for-profit community-managed specialist mental health service provider in Adelaide, South Australia were recruited. Four focus group sessions were conducted between February 2020 and March 2021. All sessions were co-facilitated by a peer practitioner with lived experience. Sessions were audio recorded and transcribed verbatim. Participants (n = 27) reported that provision of medication education was inadequate and, in some cases, non-existent. There was an apparent lack of support for monitoring and managing common side effects, such as weight gain. Participants described not being involved in any decision-making processes and that establishing and maintaining a therapeutic relationship with their healthcare providers was challenging. Perceived stigma remains a barrier in accessing healthcare. Despite participants regularly interacting with a range of healthcare providers, findings highlight key gaps in care, particularly medication education and establishing a therapeutic relationship with their healthcare providers. Future mental health reforms should consider the provision of additional medication education in community settings, such as at not-for-profit organisations. Moreover, healthcare providers should take a proactive approach in establishing therapeutic relationships.

Facilitators and Barriers of Medication Adherence Based on Beliefs of Persons with Bipolar Disorder: A Qualitative Study

One of the big challenges in treating individuals with bipolar disorder (BD) is nonadherence to medication. This is the principal factor associated with a worse prognosis or outcome of the disease. This study aimed to explore and analyze the individual perceptions that people with BD have about the positive and negative aspects when taking medication. A descriptive and interpretative study was carried out using the qualitative research paradigm with the use of the analytical technique of discourse analysis, extracting the data through the completion of focus groups. Participants’ speech was digitally audio-recorded in digital format. In order to complete the codification of the participants’ speech content, we relied on the qualitative data analysis (using the QRS NVivo 10 computer software). Thirty-six participants diagnosed with bipolar disorder took part in our study. In the participants’ speech concerning the main barriers to pharmacological treatment, three key topics were identified. Perceived facilitators were summarized in four factors. The main facilitators regarding the use of pharmacological treatment in individuals with BD were the ones related with the perceived need for treatment in the acute phase, the recognition of the illness, the shared clinical decision, and the causal biological attribution in the chronic phase. In terms of perceived barriers, social control was identified in both phases, adverse effects in the acute phase, and the absence of effective treatment in the chronic state.

The impact of illness perception on functionality, pain, stiffness, and activity of daily living after total hip replacement surgery

OBJECTIVE

According to the Common Sense Model (CSM), cognitive and emotional representations influence recovery. We used groups of individuals grouping multiple cognitive representations (schemas) to predict the recovery process after total hip arthroplasty (THR).

METHODS

The aim of this prospective cohort study with three collection time points was to examine the significance of these schemas for functionality three and six months after THR. We assessed illness perception with the Illness Perception Questionnaire-Revised and the functionality with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Data were collected four weeks before (n = 317), three (n = 268), and six months after (n = 292) primary THR. Groups of individuals with the same schemas were identified using a two-step cluster analysis across cognitive representations. Controlling for WOMAC variables (functionality, stiffness, pain, and activities of daily living) before THR, we calculated the regression of schemas and emotional representations before THR on WOMAC variables after THR.

RESULTS

Before THR, two cognitive schemes were found: Schema One: medium identity, long duration, many consequences, low personal and treatment control, and low coherence; Schema Two: low identity, short timeline, low consequences, and high personal and treatment control. Patients with Schema Two had better functionality and lower pain and stiffness three months after surgery compared to those with Schema One. After three months, the influence of cognitive schemas was stronger on functionality than that of emotional representation (f²: 0.04 /0.02).

CONCLUSION

Further study is needed to determine whether a psychological intervention can change Schema One.

How I see is how I feel. Identification of illness perception schema and its association with adaptation outcomes in multiple sclerosis - a 5-year prospective study

The aim of the study was to assess the role of illness perception in adaptation to chronic disease among patients with relapsing-remitting multiple sclerosis (RRMS). The differences between the obtained configurations of the illness perception components during four measurements and the model of predictions of the values of adaptation indicators, i.e. depression, anxiety and quality of life during subsequent measurements, were analyzed. Illness representation was assessed at baseline via the Illness Representation Questionnaire–Revised. The adaptation indicators–anxiety, depression (measured by HADS) and quality of life (measured by MSIS-29) were measured at baseline and three more times over a five-year period. The k-means cluster analysis (with two-way and repeated measures ANOVA) was conducted in a group of 90 patients (48.89% women and 51.11% men). Subsequently, the mean values of depression, anxiety, physical and psychological quality of life were compared between the clusters using the Kruskall-Wallis test. Finally, a cross-lagged panel modeled for HADS and MSIS-29 subscales in each measurement occasion (T1-T4). Three different illness perception clusters (Anxious, Realistic and Fatalistic Illness Perception named AIP, RIP and FIP) were composed which differentiated the depression, anxiety, quality of life level and age. FIP showed the lowest adaptation outcomes with small differences between AIP and RIP. It was also significantly characterized by the highest age. The positive adaptation indicators were related to the RIP cluster. The model presented rather satisfactory fit (χ²(48) = 81.05; CFI = .968; TLI = .925; SRMR = .050) with slightly inflated RMSEA = .087 (90%CI .053-.120). Based on initial measurements of individual characteristics, it was possible to predict the functioning of patients after several years. For patients with AIP, the covariance of anxiety and depression was significant, for patients with RIP–depression and anxiety, and for patients with FIP–depression. In addition, each of the variables was a predictor of subsequent measurements in particular time intervals, illustrating the dynamics of changes. Results highlight that illness perceptions formed at the beginning of RRMS are important for the process of adaptation to the disease. Moreover, they showed the differences between the adaptation outcomes supporting the idea that a cognitive representation might be important for the level of psychological functioning.

A reduced state of being: The role of culture in illness perceptions of young adults diagnosed with depressive disorders in Singapore

Illness perceptions form a key part of common-sense models which are used widely to explain variations in patient behaviours in healthcare. Despite the pervasiveness of depressive disorders worldwide and in young adults, illness perceptions of depressive disorders have not yet been well understood. Moreover, while a high proportion of cases of depressive disorders reside in South-east Asia, few have explored illness perceptions that are culturally relevant to this region. To address these limitations, this study aimed to understand illness perceptions of young adults diagnosed with depressive disorders. Face-to-face semi-structured interviews were conducted among Chinese, Malay, and Indian young adults aged 20 to 35 years old, who were seeking treatment at a psychiatric hospital. Data reached saturation after 33 interviews (10 to 12 interviews per ethnic group) and five themes emerged from the thematic analysis: 1) A reduced state of being experienced at a point of goal disengagement, 2) the accumulation of chronic stressors in a system that demands success and discourages the pursuit of personally meaningful goals, 3) a wide range of symptoms that are uncontrollable and disabling, 4) poor decision making resulting in wasted opportunities, with some positive takeaways, and 5) accepting the chronicity of depression. Young adults typically experienced depression as a reduced state of being and it was thought of cognitively as an entity that may be a part of or separate from the self. Over and beyond these aspects of cognitive representations was the emergence of themes depicting conflicts and dilemmas between the self and the social environment that threatened self-identity and autonomy. Addressing these conflicts in therapy would therefore be of utmost relevance for young adults recovering from depressive disorders in the local setting.

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.

Efficacy of Phase 1 of Life Goals Programme on symptom reduction and mood stability for bipolar disorder

BACKGROUND

Life Goals Programme (LGP) was developed as a psychological intervention for bipolar disorder, with its structured 6-session psychoeducation phase (Phase 1) targeting understanding of the disorder, medication adherence, early warning signs, and coping with symptoms and triggers. The present study tested the efficacy of Phase 1 of the LGP on symptom recovery and moment-by-moment mood stability, as well as medication adherence and quality of life.

METHODS

Adults with bipolar disorder were randomly allocated to the LGP condition (six weekly group sessions) or the waitlist condition (six weeks of standard care, followed by the same LGP intervention). Participants were assessed before and after treatment, and at 6-month follow up. Waitlist participants were additionally assessed at baseline. Assessment included a clinical interview (SCID, MADRS, YMRS, and HAM-A), self-reported questionnaires, and 6-day experience sampling assessment on a mobile device.

RESULTS

64 out-patients with bipolar disorder (44 Bipolar I and 20 Bipolar II subtypes) participated in this study. LGP was well received and attended. Following LGP, there were significant improvements in knowledge about illness and level of anxiety, which were of large effect sizes and sustained at 6-month follow-up. Experience sampling assessment revealed small but significant improvements in moment-by-moment mood stability. Improvement in medication adherence was significant at 6 months and was of a moderate-to-large effect size. Changes in anxiety and mood stability were significantly greater following LGP than standard care.

LIMITATIONS

Our results warrant further testing against active control.

CONCLUSIONS

There was a robust improvement in emotional regulation following the 6-week LGP.

Bipolar I disorder: a qualitative study of the viewpoints of the family members of patients on the nature of the disorder and pharmacological treatment non-adherence

BACKGROUND

Bipolar disorder is a common psychiatric disorder with a massive psychological and social burden. Research indicates that treatment adherence is not good in these patients. The families' knowledge about the disorder is fundamental for managing their patients' disorder. The purpose of the present study was to investigate the knowledge of the family members of a sample of Iranian patients with bipolar I disorder (BD-I) and to explore the potential reasons for treatment non-adherence.

METHODS

This study was conducted by qualitative content analysis. In-depth interviews were held and open-coding inductive analysis was performed. A thematic content analysis was used for the qualitative data analysis.

RESULTS

The viewpoints of the family members of the patients were categorized in five themes, including knowledge about the disorder, information about the medications, information about the treatment and the respective role of the family, reasons for pharmacological treatment non-adherence, and strategies applied by families to enhance treatment adherence in the patients. The research findings showed that the family members did not have enough information about the nature of BD-I, which they attributed to their lack of training on the disorder. The families did not know what caused the recurrence of the disorder and did not have sufficient knowledge about its prescribed medications and treatments. Also, most families did not know about the etiology of the disorder.

CONCLUSION

The lack of knowledge among the family members of patients with BD-I can have a significant impact on relapse and treatment non-adherence. These issues need to be further emphasized in the training of patients' families. The present findings can be used to re-design the guidelines and protocols in a way to improve treatment adherence and avoid the relapse of BD-I symptoms.

Factors associated with dropout from treatment: An exploratory study

AIM

To evaluate the factors associated with treatment dropout among patients attending the psychiatric outpatient services.

MATERIALS AND METHODS

Seventy-two patients who dropped out from treatment were contacted and they were compared with 200 regular attendees for sociodemographic and clinical variables, medication adherence, treatment satisfaction, attitude toward medication, insight, and therapeutic alliance.

RESULTS

Compared to "regular attendees," those who dropped out from treatment were significantly older, were more likely to be married, had higher age of onset, had longer duration of illness, received less supervision for medication at home, higher proportion of them continued to remain symptomatic, had more negative attitude toward medications, had poorer insight, were poorly complaint with medication, were less satisfied with the treatment provided, and had poor quality of therapeutic alliance.

CONCLUSION

This study suggests that dropout from treatment can be avoided by addressing issues of negative attitude toward medications, improving satisfaction with the treatment contact and enhancing therapeutic alliance.

Interferon gamma release assay tests are associated with persistence and completion of latent tuberculosis infection treatment in the United States: Evidence from commercial insurance data

Background

Risk-targeted testing and treatment of latent tuberculosis infection (LTBI) is a critical component of the United States’ (US) tuberculosis (TB) elimination strategy, but relatively low treatment completion rates remain a challenge. Both treatment persistence and completion may be facilitated by diagnosing LTBI using interferon gamma release assays (IGRA) rather than tuberculin skin tests (TST).

Methods

We used a national sample of administrative claims data to explore associations diagnostic test choice (TST, IGRA, TST with subsequent IGRA) and treatment persistence and completion in persons initiating a daily dose isoniazid LTBI treatment regimen in the US private healthcare sector between July 2011 and March 2014. Associations were analyzed with a generalized ordered logit model (completion) and a negative binomial regression model (persistence).

Results

Of 662 persons initiating treatment, 327 (49.4%) completed at least the 6-month regimen and 173 (26.1%) completed the 9-month regimen; 129 (19.5%) persisted in treatment one month or less. Six-month completion was least likely in persons receiving a TST (42.2%) relative to persons receiving an IGRA (55.0%) or TST then IGRA (67.2%; p = 0.001). Those receiving an IGRA or a TST followed by an IGRA had higher odds of completion compared to those receiving a TST (aOR = 1.59 and 2.50; p = 0.017 and 0.001, respectively). Receiving an IGRA or a TST and subsequent IGRA was associated with increased treatment persistence relative to TST (aIRR = 1.14 and 1.25; p = 0.027 and 0.009, respectively).

Conclusions

IGRA use is significantly associated with both higher levels of LTBI treatment completion and treatment persistence. These differences are apparent both when IGRAs alone were administered and when IGRAs were administered subsequent to a TST. Our results suggest that IGRAs contribute to more effective LTBI treatment and consequently individual and population protections against TB.

Psychological factors involved in psychopharmacological medication adherence in mental health patients: A systematic review

BACKGROUND

Psychopharmacological medication adherence is essential for psychiatric patients' treatment and well-being.

OBJECTIVE

This review aimed to identify psychological factors related to health control that have been linked to psychopharmacological medication adherence in psychiatric patients.

METHODS

A literature search was performed through the databases Medline, PubMed, PsycINFO, and Google Scholar to identify relevant studies published before October 15th, 2019. Articles published in peer-reviewed journals that analyzed the psychological factors of health belief and health control involved in psychopharmacological medication adherence in a psychiatric population were included.

RESULTS

The search identified 124 potentially relevant papers, 29 of which met the eligibility criteria. The final sample was 222 adolescents, most with a diagnosis of attention deficit/hyperactivity disorder (ADHD), and 6139 adults diagnosed especially with schizophrenia spectrum disorder, bipolar disorder, or depressive disorder. Results suggested that medication adherence is associated with health beliefs and psychological variables, such as self-efficacy and locus of control. Family support was also positively related to medication adherence.

CONCLUSION

Psychopharmacological medication adherence requires a consideration of multicausality, which depends on sociodemographic, clinical, and psychological factors.

PRACTICE IMPLICATIONS

These findings should be considered in the development and implementation of psychological interventions focused on self-control and family support.

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

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

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.

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.

Attitude and perceptions of patients towards long acting depot injections (LAIs)

BACKGROUND

Despite the well-established efficacy of the long acting depot injectable (LAIs) antipsychotics, these are significantly underused and underutilized by the mental health professionals, with a belief that patients will not accept the same.

AIMS & OBJECTIVES

To explore the acceptability and perception of patients towards various psychiatric treatments, with specific focus on LAIs. Additionally the study aimed to compare the acceptability of various types of treatments including LAIs between patients with severe mental disorders (Psychotic disorders and Bipolar disorder) and those with Common mental disorders (Anxiety, neurotic and depressive disorders).

METHODOLOGY

A self-designed semi-structured questionnaire was used to evaluate the preferred treatment options of all the new patients attending the psychiatry outpatient clinic of a tertiary care hospital. Depending on the response, they were further probed for the reasons for accepting or rejecting the LAIs.

RESULTS

2659 patients were interviewed who were divided into two groups (Group I - 321 subjects with psychotic disorders and 120 subjects with bipolar affective disorder (BPAD) and Group II - 2218 subjects with neurotic, stress-related and unipolar depressive disorders). More than three-fourth (78.8%) of the participants in the whole study sample opted for tablets only as their first preferred choice and injectables were opted by about 5% of the participants only, with no significant difference between the 2 groups. After being explained about LAIs, one fourth of the participants (24.9%) reported that they may consider LAIs, without any significant difference between the 2 groups. Among those who refused to take LAIs even after explanation, the commonly reported reasons were difficulty in visiting hospital frequently for the injectables (41.69%), injectables being painful (19.41%), fear of injections (13.96%), no need to take LAIs (12.45%) and preference to take some other types of medicines (8.52%).

CONCLUSIONS

Considering the fact that LAIs are highly underused in patients with severe mental disorders and there is lack of awareness about LAIs among patients with severe mental disorders, the present study findings suggest that there is reasonable level of acceptance of LAIs among patients with severe mental disorders when explained about the same.

Better understanding the influence and complexity of beliefs on medication adherence in asthma

OBJECTIVE

The aim was to better understand how beliefs influence medication adherence in asthma.

METHODS

All participants were prescribed an inhaled corticosteroid for a diagnosis of asthma. Each participant completed a survey consisting of: Beliefs about Medicines Questionnaire (BMQ), Brief-Illness Perception Questionnaire (B-IPQ) and Multi-dimensional Health Locus of Control Scale (MHLCS). Adherence to inhaled corticosteroids was elicited using the Medication Adherence Report Scale (MARS). Multiple linear regression with interaction effects was used to identify significant predictors of medication adherence and interactions between beliefs.

RESULTS

A total of 198 participants completed the survey. The mean(±SD) MARS score was 19.2(±4.5). A multivariable model (adjusted R² = 0.39) predicted adherence using: age, asthma hospitalisation, timeline (B-IPQ) subscale, necessity and concern (BMQ) subscales, doctor (MHLCS) subscale and the two interaction effects (concerns [BMQ] moderated by chance [MHLCS] and treatment control [B-IPQ] moderated by understanding [B-IPQ]).

CONCLUSION

The findings of this study contribute to a better understanding of the role of beliefs in medication adherence in asthma. Certain beliefs meaningfully interrelate and change the relationship they have with medication adherence.

PRACTICE IMPLICATIONS

If these beliefs are causally related to medication adherence and can be intervened upon, the findings are useful for providing targets to personalise adherence support.

Participation in decision-making about medication: A qualitative analysis of medication adherence

Rates of relapse in BD are high with medication nonadherence identified as an important contributor to relapse. Psychopharmacology remains a key component to the treatment of BD; therefore, increased understanding of medication use and ways to promote greater adherence is essential. The aim of the study was to identify how participants with BD experience taking prescribed medication. Participants had BD I or BD II, were users of specialist mental health services, aged 18-64 years, euthymic, mildly hypomanic or depressed, and on any combination of medication. Exclusion criteria were minimal. A semistructured interview was completed exploring patients' views of BD and factors influencing adherence based on the Subjective Experience of Medication Interview. An inductive thematic analysis was used to identify themes. The study participants (n = 36) had predominantly bipolar I (78%) and were female (69%), and of New Zealand European ethnicity (67%) with 14% Maori. The mean age was 41 years (SD: 12.0). Findings from the thematic analysis generated three themes: Learning about the clinical meaning of having BD, Understanding how to use medication, and Understanding what works for me. The qualitative nature of our study limits the generalizability of our findings to a broader population of individuals with BD. The participants developed confidence in being in charge of their BD through a process of learning about BD and medication and understanding what this meant for them. The findings support greater emphasis on collaborative approaches that recognize the expertise of the individual with BD and the clinician.

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.

Reasons for Nonadherence to Psychiatric Medication and Cardiovascular Risk Factors Treatment Among Latino Bipolar Disorder Patients Living in Puerto Rico: A Qualitative Study

Latinos with bipolar disorder (BD) have a high rate of nonadherence to psychiatric medication and treatment for other medical conditions such as cardiovascular disease (CVD) risk factors than non-Latinos with BD. The aim of this study is to identify patients' perspectives on the reasons for nonadherence to psychiatric medication and for CVD risk factors conditions in outpatients with BD. Three focus group sessions were held for a total of 22 adults ranging from 23 to 60 years old. Participants had BD, Type I/II and CVD risk factors. Audio-recordings of focus groups were transcribed and a content analysis was performed. Reasons identified as barriers to adherence were somewhat different for BD medications in comparison to CVD risk factors suggesting the need for integrated interventions targeting these barriers to adherence for both BD and CVD risk factors.

Illness perceptions and adherence in bipolar disorder: An exploratory study

BACKGROUND

According to the Self-Regulation Model, illness perceptions influence an individual's coping (such as the taking of treatment) and emotional response to their illness. Emerging research suggests that this model could be used to explore illness perceptions in mental health. The aim of this exploratory study is, firstly, to measure and describe illness perception in French patients with a bipolar diagnosis and, secondly, to explore associations between illness perceptions and adherence in this population.

METHOD

Thirty-eight French patients with bipolar disorder completed the Illness Perception Questionnaire for Schizophrenia (except the identity dimension). We measured medication adherence with the Medication Adherence Rating Scale.

RESULTS

Our results showed that patients with high perceptions concerning treatment control, low perceptions of negative emotions of their mental illness, low perception of consequences and high comprehension of their disorder had a better adherence.

CONCLUSIONS

Illness perceptions can provide a framework for understanding adherence in bipolar disorder, and the findings could have important clinical and research implications.

Illness Perceptions in Patients of Schizophrenia: A Preliminary Investigation from Lahore, Pakistan

Background and Objective:

Patient’s perception of their illness influences their healthcare decisions. The objectives of this study were to explore patient’s own beliefs about their illness (Schizophrenia) and perceived social support, and its impact on their attitudes toward pharmacological treatment in Lahore, Pakistan.

Methods:

This study was conducted at Mayo Hospital Lahore from March to September 2016. Hundred individuals suffering from Schizophrenia completed four questionnaires; a socio-demographic questionnaire, the Illness Perception Questionnaire for Schizophrenia(IPQ-S), Drug attitude Inventory-10 (DAI) and Multidimensional Scale of Perceived Social Support (PSS).

Results:

Stress, family problems, lack of friends & financial worries were endorsed strongly by patients as cause of their mental illness. Ambiguity regarding their mental illness duration and personal control was observed. Patients’ perceived significant negative consequences, negative emotional response, as well as had poor understanding of their mental illness and treatment effectiveness. Statistically significant gender differences in treatment control and illness coherence subscales of IPQS were observed. Drug attitude inventory was positively correlated with Treatment control subscale (p < .01) and negatively correlated with Illness coherence subscale of IPQS (p < .05). The negative consequences subscale and perceived social support was negatively correlated (p < .01).

Conclusion:

Patient’s perception about their own illness is predictor of their drug taking attitude and perceived social support. Study results should help to develop new interventions to correct inaccurate beliefs in patients with schizophrenia to improve illness outcome.

Barriers and facilitators of adherence to antidepressants among outpatients with major depressive disorder: A qualitative study

BACKGROUND

One of the major challenges in treating major depressive disorder (MDD) is patients' non-adherence to medication. This study aimed to explore the barriers and facilitators of patients' adherence to antidepressants among outpatients with MDD.

METHODS

Semi-structured and individual in-depth interviews were conducted among patients with MDD who were taking antidepressants, in the psychiatric clinic of a government-run hospital in Malaysia. Participants were purposively sampled from different genders and ethnicities. Interviews were conducted using a validated topic guide, and responses were audio-recorded, transcribed verbatim, checked, and analyzed using the grounded theory approach.

RESULTS

A total of 30 patients were interviewed. Forty different themes and sub-themes were identified which were conceptually divided into two distinct categories related to barriers and facilitators to adherence. The barriers were: patient-specific, medication-specific, healthcare provision and system, social-cultural, and logistics. The facilitators were: having insight, perceived health benefits, regular activities, patient-provider relationship, reminders, and social support networks.

CONCLUSIONS

Patient-specific barriers and medication side effects were the major challenges for adhering to treatment. Perceived health benefits and having insight on the need for treatment were the most frequently cited facilitators. Targeted interventions should be developed to address the key barriers, and promote measures to facilitate adherence in this group of patients.

A Reexamination of Nonpsychiatric Medication Adherence in Individuals With Bipolar Disorder and Medical Comorbidities

Individuals with bipolar disorder (BD) have high rates of nonadherence, medical illness, and premature mortality. This analysis reexamined correlates of poor adherence to nonpsychiatric medication in 73 patients with BD and medical comorbidities. The majority was female (74%) and African American (77%) with mean age of 48.08 (SD, 8.04) years, mean BD duration of 28.67 (SD, 10.24) years, mean years of education of 12.01 (SD, 1.87), and mean proportion of days with missed doses in past week of 43.25 (SD, 31.14). Sex, age, education, race, and living alone did not correlate with adherence. More BD medications and more severe psychiatric symptoms correlated with worse adherence. Specifically, poor adherence correlated with the retardation and vegetative factors of Montgomery-Åsberg Depression Rating Scale and affect factor of the Brief Psychiatric Rating Scale. Among poorly adherent patients with BD and medical comorbidities, the number of BD medications, tension/anxiety, and somatic symptoms of depression related to worse nonpsychiatric medication adherence.

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.

Non-Compliance and Related Factors in Patients With Bipolar I Disorder: A Six Month Follow-Up Study

Background

Medication treatment compliance among bipolar patients is quite widespread.

Objectives

Treatment compliance depends on multiple factors. The aim of this study was to evaluate the predicting factors of noncompliance in patients with bipolar I disorder admitted to an Iranian hospital during a six-month follow up period.

Materials and Methods

This cross-sectional study included 47 bipolar I disorder subjects who were admitted to the Iran psychiatric hospital and that were chosen using a non-randomized convenient sampling model. The patients were assessed at baseline, and at two and six months after admission. For evaluating the patients, we used the medication possession ratio (MPR), the drug attitude inventory (DIA-10), the young mania rating scale (Y-MRS) and the scale for the assessment of positive symptoms (SAPS). The data were analyzed using a general linear model by SPSS 16 software.

Results

The repeated measures analysis revealed that medication compliance increased successively (P = 0.045), and age, gender and symptom severity did not alter the pattern.

Conclusions

There is an increasing pattern in treatment compliance in bipolar I disorder patients, regardless of the known predicting factors for nonadherence.

What is it like to take antipsychotic medication? A qualitative study of patients with first-episode psychosis

ACCESSIBLE SUMMARY

What is known on the subject? Antipsychotic drugs are an important part of treatment for most patients with first episode psychosis. We do not know much about what it is like to take these drugs from the patient's point of view. What this paper adds to existing knowledge? We talked to 20 young people with psychosis about their experiences of taking antipsychotic drugs. Patients relationship with medication was complex, young people found medication often to be both good and bad at the same time. We were interested in how seemingly trivial issues--colour, taste, size, name--could be very important to young people and could result in them stopping. What are the implications for practice? We think our study highlights the complicated internal struggles that people with first episode psychosis have with medication. Our study highlights how Nurses and Doctors need to try and better understand what it is like to take these drugs and work collaboratively with patients to support them to make informed choices about treatment.

BACKGROUND

Low-dose antipsychotic medication is an important part of treatment for people experiencing a first episode of psychosis. Little is known about this group of patients' experiences of taking medication.

METHOD

A qualitative study of purposively sampled young people experiencing a first episode of psychosis was carried out. A mental health nurse working in the early psychosis team interviewed participants using a structured topic guide. Interviews were subjected to thematic analysis.

RESULTS

Interviews were completed with 20 young people. Thematic analysis generated six themes: (1) the drugs do work, (2) the drugs don't work (as well as I'd like), (3) side effects, (4) the indirect effects of medication, (5) rage against the machine and (6) the not trivial issues about medication.

CONCLUSION

Our overarching meta-theme was that young people's experience of taking antipsychotics was complex; medication was often considered good and bad at the same time. Our observations underpin the importance of helping patients think through the use of antipsychotic medication in supporting their personal recovery.

Time to lack of persistence with pharmacological treatment among patients with current depressive episodes: a natural study with 1-year follow-up

INTRODUCTION

Medication nonadherence remains a big challenge for depressive patients. This study aims to assess and compare the medication persistence between unipolar depression (UD) and bipolar depression (BD).

METHODS

A total of 146 UD and 187 BD patients were recruited at their first index prescription. Time to lack of persistence with pharmacological treatment (defined as a gap of at least 60 days without taking any medication) was calculated, and clinical characteristics were collected. Final diagnosis was made at the end of 1-year follow-up.

RESULTS

A total of 101 (69.2%) UD and 126 (67.4%) BD patients discontinued the treatment, with a median duration of 36 days and 27 days, respectively. No significant difference was found between UD and BD in terms of time to lack of persistence with pharmacological treatment. The highest discontinuation rate (>40%) occurred in the first 3 months for both groups of patients. For UD patients, those with a higher risk of suicide (odds ratio [OR] =0.696, P=0.035) or comorbidity of any anxiety disorder (OR =0.159, P<0.001) were less likely to prematurely drop out (drop out within the first 3 months), while those with onset in the summer (OR =4.702, P=0.049) or autumn (OR =7.690, P=0.012) were more likely to prematurely drop out than those with onset in the spring (OR =0.159, P<0.001). For BD patients, being female (OR =2.250, P=0.012) and having a history of spontaneous remission or switch to hypomania (OR =2.470, P=0.004) were risk factors for premature drop out, while hospitalization (OR =0.304, P=0.023) and misdiagnosis as UD (OR =0.283, P<0.001) at the first index prescription were protective factors.

LIMITATION

Conservative definition of nonadherence, low representativeness of sample.

CONCLUSION

Treatment discontinuation was frequently seen in patients with UD or BD, especially in the first 3 months of treatment. In spite of the similar pattern of medication persistence, UD and BD differ from each other in predictors of premature drop out.

Unmet needs of bipolar disorder patients

BACKGROUND

Bipolar disorder (BD) is a serious mental illness with adverse impact on the lives of the patients and their caregivers. BD is associated with many limitations in personal and interpersonal functioning and restricts the patients' ability to use their potential capabilities fully. Bipolar patients long to live meaningful lives, but this goal is hard to achieve for those with poor insight. With progress and humanization of society, the issue of patients' needs became an important topic. The objective of the paper is to provide the up-to-date data on the unmet needs of BD patients and their caregivers.

METHODS

A systematic computerized examination of MEDLINE publications from 1970 to 2015, via the keywords "bipolar disorder", "mania", "bipolar depression", and "unmet needs", was performed.

RESULTS

Patients' needs may differ in various stages of the disorder and may have different origin and goals. Thus, we divided them into five groups relating to their nature: those connected with symptoms, treatment, quality of life, family, and pharmacotherapy. We suggested several implications of these needs for pharmacotherapy and psychotherapy.

CONCLUSION

Trying to follow patients' needs may be a crucial point in the treatment of BD patients. However, many needs remain unmet due to both medical and social factors.

The Australasian Hepatology Association consensus guidelines for the provision of adherence support to patients with hepatitis C on direct acting antivirals

BACKGROUND

Hepatitis C is a blood-borne virus primarily spread through sharing of drug-injecting equipment. Approximately 150 million people worldwide and 230,000 Australians are living with chronic hepatitis C infection. In March 2016, the Australian government began subsidizing direct acting antivirals (DAAs) for the treatment of hepatitis C, which are highly effective (95% cure rate) and have few side effects. However, there is limited evidence to inform the provision of adherence support to people with hepatitis C on DAAs including the level of medication adherence required to achieve a cure.

METHODOLOGY

In February 2016, a steering committee comprising four authors convened an expert panel consisting of six hepatology nurses, a hepatologist, a pharmacist, a consumer with hepatitis C and treatment experience, and a consumer advocate. The expert panel focused on the following criteria: barriers and enablers to DAA adherence; assessment and monitoring of DAA adherence; components of a patient-centered approach to DAA adherence; patients that may require additional adherence support; and interventions to support DAA adherence. The resultant guidelines underwent three rounds of consultation with the expert panel, Australasian Hepatology Association (AHA) members (n=12), and key stakeholders (n=7) in June 2016. Feedback was considered by the steering committee and incorporated if consensus was achieved.

RESULTS

Twenty-four guidelines emerged from the evidence synthesis and expert panel discussion. The guidelines focus on the pretreatment assessment and education, assessment of treatment readiness, and monitoring of medication adherence. The guidelines are embedded in a patient-centered approach which highlights that all patients are at risk of nonadherence. The guidelines recommend implementing interventions focused on identifying patients' memory triggers and hooks; use of nonconfrontational and nonjudgmental language by health professionals; and objectively monitoring adherence.

CONCLUSION

These are the first guidelines to support patients and health professionals in the delivery of clinical care by identifying practical adherence support interventions for patients taking DAAs.

Medication taking behaviors among breast cancer patients on adjuvant endocrine therapy

PURPOSE

To explore how symptoms and psychosocial factors are related to intentional and unintentional non-adherent medication taking behaviors.

METHODS

Included were postmenopausal women with hormone receptor positive, stage I-IIIA breast cancer, who had completed surgery, chemotherapy, and radiation, and were taking endocrine therapy. Self-administered, standardized measures were completed during a routine clinic visit: Brief Fatigue Inventory, Brief Pain Inventory, Menopause Specific Quality of Life Questionnaire, Functional Assessment of Cancer Therapy General and Neurotoxicity scales, and Self-Efficacy for Appropriate Medication Use Scale. Regression analyses were performed to determine the degree to which demographic, medical, symptom, and psychosocial variables, explain intentional, such as changing one's doses or stopping medication, and unintentional, such as forgetting to take one's medication, non-adherent behaviors.

RESULTS

Participants were 112 women: mean age 64 (SD = 9) years; 81% white; mean time from surgery 40 (SD = 28) months; 49% received chemotherapy (39% including a taxane); mean time on endocrine therapy, 35 (SD = 29.6) months; 82% taking an aromatase inhibitor. Intentional and unintentional non-adherent behaviors were described in 33.9% and 58.9% of participants, respectively. Multivariate analysis showed that higher self-efficacy for taking medication was associated with lower levels of unintentional (p = 0.002) and intentional (p = 0.004) non-adherent behaviors. The presence of symptoms (p = 0.03) and lower self-efficacy for physician communication (p = 0.009) were associated with higher levels of intentional non-adherent behaviors.

CONCLUSIONS

These results suggest that women who report greater symptoms, lower self-efficacy for communicating with their physician, and lower self-efficacy for taking their medication are more likely to engage in both intentional and unintentional non-adherent behaviors.

Illness perception of dropout patients followed up at bipolar outpatient clinic, Turkey

Dropout is a common problem in the treatment of psychiatric illnesses including bipolar disorders (BD). The aim of the present study is to investigate illness perceptions of dropout patients with BD. A cross sectional study was done on the participants who attended the Mood Disorder Outpatient Clinic at least 3 times from January 2003 through June 2008, and then failed to attend clinic till to the last one year, 2009, determined as dropout. Thirty-nine dropout patients and 39 attendent patients with BD were recruited for this study. A sociodemographic form and brief illness perception questionnaire were used to capture data. The main reasons of patients with BD for dropout were difficulties of transport (31%), to visit another doctor (26%), giving up drugs (13%) and low education level (59%) is significant for dropout patients. The dropout patients reported that their illness did not critically influence their lives, their treatment had failed to control their illnesses, they had no symptoms, and that their illness did not emotionally affect them. In conclusion, the nonattendance of patients with serious mental illness can result in non-compliance of therapeutic drug regimens, and a recurrence of the appearance symptoms. The perception of illness in dropout patients with BD may be important for understanding and preventing nonattendance.

Trajectories of medication attitudes and adherence behavior change in non-adherent bipolar patients

OBJECTIVES

While medication treatment is necessary for the successful management of bipolar disorder (BD), non-adherence rates are up to 60%. Although medication attitudes are believed to be relevant to adherence behavior, few studies have investigated the trajectories of adherence change. This study evaluated attitudinal correlates of adherence conversion in 86 poorly adherent individuals with BD.

METHODS

This secondary analysis pooled data from two uncontrolled prospective trials of customized adherence enhancement (CAE), a psychosocial intervention delivered over 4-6 weeks. Poor adherence was defined as missing at least 20% of prescribed BD medication based on the self-reported Tablets Routine Questionnaire (TRQ). The sample was dichotomized into converters who achieved good adherence (N=44) and non-converters who remained poorly adherent (N=21). Converters vs. non-converters were compared on adherence, attitudes, and symptoms at baseline, 6 weeks and 3 months.

RESULTS

At baseline, converters and non-converters were similar demographically and clinically, but converters were less non-adherent (32% doses missed) than non-converters (59% missed). At 6 weeks, converters had better attitudes than non-converters. At 3 months, converters maintained improvements, but group differences were less pronounced due to some improvement in non-converters. Converters had better adherence at 3 months and trajectories differed for the groups on attitudes. Symptoms gradually improved for both converters and non-converters.

CONCLUSIONS

Over two-thirds of poorly adherent BD patients who received CAE converted to good adherence. Improved medication attitudes may be a driver of improved adherence behavior and ultimately reduce BD symptoms.

Effects of mood state on divided attention in patients with bipolar disorder: evidence for beneficial effects of subclinical manic symptoms

A relatively small number of studies have been dedicated to the differential effects of the current mood state on cognition in patients with a bipolar disorder (BD). The aim of the current study was to investigate the effect of current mood state on divided attention (DA) performance, and specifically examine possible beneficial effects of the (hypo-) manic state. Over a maximum period of 24 months, medication use, divided attention test (a subtest of the Test for Attentional Performance (TAP)) was assessed every 6 months in 189 outpatients with BD. Data were analyzed with multilevel regression analysis (i.e. linear mixed models). DA performance varied considerable over time within patients. Corrected for psychotropic medication a significant quadratic relationship between manic symptoms and DA performance was found, with mild hypomanic symptoms having a positive influence on divided attention scores and moderate to severe manic symptoms having a negative influence. No association between depressive symptoms and DA performance was found. In future research on mania and cognition as well as in the clinical practice both the beneficial and negative effects of mania should be taken into account.

Modifiable risk factors for adherence to adjuvant endocrine therapy among breast cancer patients

OBJECTIVE

Breast cancer incidence and mortality are declining due to improvements in early detection and treatment. One advance in treatment is the development of adjuvant endocrine therapy (AET) for women with hormone receptor positive breast cancer. Despite strong evidence linking AET to better health outcomes, AET adherence continues to be suboptimal. This study tests the hypothesis that patient beliefs about medication mediate the relationship between frequency of physician communication and AET adherence.

METHODS

This cross-sectional study utilizes data from patient self-report and medical chart abstraction (N=200). Survey measures included frequency of physician communication, patient beliefs about medicine, AET adherence, and demographic characteristics.

RESULTS

Necessity beliefs mediated the relationship between frequency of physician communication and medication adherence (necessity beliefs β=.18, p<.05; physician communication β=.13, p>.05). There was no evidence of medication concerns mediating the relationship between frequency of physician communication and medication adherence.

CONCLUSION

More frequent physician communication that shapes what patients believe about AET importance may be associated with greater AET adherence; however, frequent physician communication that shapes patient concerns about side effects may not be associated with greater AET adherence.

PRACTICE IMPLICATIONS

Research is needed to enhance understanding of the type of physician communication that is most consistently associated with patient beliefs about medication and AET adherence.

What is it like to be diagnosed with bipolar illness, borderline personality disorder or another diagnosis with mood instability?

Patients with mood instability represent a significant proportion of patients with mental illness. Important lessons need to be learnt about how current assessment processes do not meet their expectations. Changes at various levels, including medical and nursing education, service provision and research priorities, appear necessary if we are to help our patients better.

Mood disorders medications: predictors of nonadherence - review of the current literature

Studies have shown that there are several factors that predict nonadherence among patients with mood disorders. The aim of the present review is to identify the predictors of nonadherence among these patients. A careful review of the literature was conducted investigating several potential predictors of nonadherence among patients with mood disorders. A total of 217 relevant articles from peer-reviewed journals were considered, and articles that met our inclusion criteria (n = 54) were selected for this review. The authors identified several predictors of nonadherence among patients with mood disorders including younger age (below 40 years old), comorbidity with substance use and personality disorders, patients' beliefs, poor insight, illness severity, treatment-related side effects, specific features of the disease and a poor therapeutic alliance. Substance use disorder and illness severity are significant predictors of nonadherence especially in patients with bipolar disorder; whereas, treatment side effects are of primary importance for depressive disorder. The authors could not carry out a meta-analysis given that the studies considered in this review assessed patients at different time points and included different measurements of nonadherence. Moreover, articles cited in this review may reflect the authors' choice, and the authors did not investigate the adherence to a specific class of drugs commonly used in the management of mood disorders. Given the high social, clinical and economic impact of nonadherence among patients who are affected by mood disorders, it is critical to recognize patients at high risk of nonadherence in order to inform future strategies to examine and improve adherence to treatment. Further research is needed to clarify this issue.

Self-reported creativity in bipolar disorder: prevalence, types and associated outcomes in mania versus hypomania

BACKGROUND

Bipolar (BP) disorder has been linked to creativity following investigation of prominent artists and controlled trials of creativity in BP disorder patients. However, it is unclear whether creativity is differentially expressed across the BP I and BP II subtypes.

METHODS

219 patients (aged 19-63 years) diagnosed with BP disorder by clinical interview and DSM-IV criteria were asked whether they tended to be more creative during hypo/manic episodes, and answered five questions about personality styles associated with creativity. Qualitative analyses were performed on a smaller subset of 69 BP patients (n=19 BP I, n=50 BP II) who provided written responses of the types of creative activities engaged in when hypo/manic and any perceived advantages or disadvantages of their creative pursuits.

RESULTS

82% of BP patients affirmed being creative when hypo/manic, with comparable results for the BP I and BP II subtypes (84% and 81% respectively). Both BP subtypes engaged mostly in writing, painting, work or business ideas and 'other' forms of art; however BP II patients were more likely to draw and be musical. Both subgroups reported the consequences of feeling good, being productive or quitting their project. BP I patients were more likely to overspend during their creative highs while BP II patients were more likely to experience improved focus and clarity. BP patients affirming creative highs were significantly more likely to report creative personality styles more generally outside of a mood episode.

LIMITATIONS

BP patients' self-reported creative activities were not retrospectively judged for quality or originality and so may reflect common creative abilities rather than exceptional quality. The impact of depressive episodes on creativity was not assessed. Uneven sample sizes in the BP I and BP II subgroups may have compromised statistical power.

CONCLUSION

Creativity during hypo/manic episodes was extremely common in both BP subtypes. While some nuances in activity type and outcomes were observed, no significant creative phenotype specific to BP I or BP II disorder emerged.

The utilization of psychopharmacological treatment and medication adherence among Medicaid enrolled children and adolescents with bipolar depression

BACKGROUND

To examine the psychotropic medication utilization and compare adherence to treatment regimens in pediatric bipolar depression patients.

METHODS

2003-2007 MAX data from four geographically diverse states were used. According to the regimen received by the patients (6-18 years) in the first month after the index bipolar depression diagnosis, patients were categorized into six mutually exclusive groups. The month to month change of treatment regimen in each group was then assessed during the 6 month post-index bipolar depression diagnosis. Adherence to each regimen was measured as continuation of the initial regimen, switch to a new regimen, augmentation with medication from a different therapeutic category, and discontinuation of all pharmacotherapies. Repeated measure analysis was conducted to compare the trend of each adherence measure across the study groups.

RESULTS

Of the 5,460 subjects identified, 15.39% received antipsychotic monotherapy, 9.43% received mood stabilizer monotherapy, 5.77% received antidepressant monotherapy, 26.48% received mood stabilizer-antipsychotic polytherapy, 22.51% received antidepressant polytherapy, and 19.89% received antipsychotic-mood stabilizer-antidepressant polytherapy. At the end of the follow-up period, over 50% of the 1st month polytherapy users and less than 50% of the monotherapy users were continuing their initial regimen. Repeated measure analysis using antipsychotic monotherapy as the reference group suggested differences in trend slopes (p<0.05).

LIMITATIONS

In absence of structured clinical evaluation, bipolar disorder diagnoses cannot be ascertained in this study.

CONCLUSIONS

Bipolar depression patients were predominantly treated with combinations of psychotropic drugs. Potentially questionable practice, such as antidepressant monotherapy was used only in a small fraction of patients. Combination regimens had better adherence as compared to monotherapies.

From self-care to hospitalization: bipolar patients' health care practices in Mexico

BACKGROUND

New research is continually improving the comprehension of bipolar disorder (BD). However, many challenges remain to be addressed, such as understanding the health care practices (HCPs) chosen by bipolar patients and the determinants of seeking treatment.

MATERIAL

Using a qualitative approach, we studied the HCPs of six patients with BD through focused interviews.

DISCUSSION

Even patients who report using primarily allopathic care usually test out and combine different HCPs.

CONCLUSION

Pathways to care in BD are composed of a combination of HCPs because patients need to develop a stock of potential treatment alternatives to deal with the suffering involved in living with BD.