Compliance as a stable function in the treatment course of bipolar disorder in patients stabilized on olanzapine: results from a 24-month observational study

Unstructured Group Support Enhances Compliance to Pharmacological Treatment by Improving Social Cognition in Patients with Bipolar Disorder: A Pilot fMRI Study

Objective

Unstructured group support (UGS) has been shown to improve the prognosis of patients with bipolar disorder (BP). However, objective evidence is needed to support implementation of UGS intervention. This study aimed to investigate the effectiveness of UGS intervention and the associated alterations in the objective indexes, mainly global function connectivity density (gFCD), in BP patients.

Methods

Remitted BP patients were enrolled and randomly assigned into a UGS group (received UGS intervention for 26 weekly UGS sessions, and a sham group (received sham intervention). The effects of UGS on adherence to the prescribed medications, social cognition, and quality of life were examined and compared between these 2 groups. Magnetic resonance imaging (MRI) was performed to determine the functional index and gFCD values, as an objective measurement of functional alterations in the brain.

Results

The compliance rate was significantly greater in the UGS group than in the sham group at the 2-year follow-up, after 26 weekly intervention sessions. The proportion of patients with increased levels of compliance to pharmacological treatment, improved social cognition, and improved quality of life were significantly higher in the UGS group than in the sham group. Furthermore, consistent with these subjective measurements, the fMRI study revealed that gFCD values significantly increased in the regions of the brain that are related to social cognition, in patients with UGS intervention.

Conclusion

UGS improves the compliance to pharmacological treatment, quality of life, and social cognition of remitted BP patients. Notably, these findings offer the first objective evidence that UGS enhances gFCD in BP patients. Thus, UGS implementation can help improve the psychiatric care for BP patients.

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

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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.

Individualized clinical management of patients at risk for Alzheimer's dementia

INTRODUCTION

Multidomain intervention for Alzheimer's disease (AD) risk reduction is an emerging therapeutic paradigm.

METHODS

Patients were prescribed individually tailored interventions (education/pharmacologic/nonpharmacologic) and rated on compliance. Normal cognition/subjective cognitive decline/preclinical AD was classified as Prevention. Mild cognitive impairment due to AD/mild-AD was classified as Early Treatment. Change from baseline to 18 months on the modified Alzheimer's Prevention Cognitive Composite (primary outcome) was compared against matched historical control cohorts. Cognitive aging composite (CogAging), AD/cardiovascular risk scales, and serum biomarkers were secondary outcomes.

RESULTS

One hundred seventy-four were assigned interventions (age 25-86). Higher-compliance Prevention improved more than both historical cohorts (P = .0012, P < .0001). Lower-compliance Prevention also improved more than both historical cohorts (P = .0088, P < .0055). Higher-compliance Early Treatment improved more than lower compliance (P = .0007). Higher-compliance Early Treatment improved more than historical cohorts (P < .0001, P = .0428). Lower-compliance Early Treatment did not differ (P = .9820, P = .1115). Similar effects occurred for CogAging. AD/cardiovascular risk scales and serum biomarkers improved.

DISCUSSION

Individualized multidomain interventions may improve cognition and reduce AD/cardiovascular risk scores in patients at-risk for AD dementia.

Treatment alliance and adherence in bipolar disorder

The clinician patient relationship lies at the core of psychiatric practice and delivery of mental health care services. The concept of treatment alliance in psychiatry has its origins in psychotherapy, but has also been influenced by several other constructs such as patient-centred care (PCC) and shared decision-making (SDM). Similarly, there has been a shift in conceptualization of treatment-adherence in psychiatric disorders including bipolar disorder (BD) from illness-centred and clinician-centred approaches to patient-centred ones. Moreover, the traditional compliance based models are being replaced by those based on concordance between clinicians and patients. Newer theories of adherence in BD place considerable emphasis on patient related factors and the clinician patient alliance is considered to be one of the principal determinants of treatment-adherence in BD. Likewise, current notions of treatment alliance in BD also stress the importance of equal and collaborative relationships, sensitivity to patients' viewpoints, sharing of knowledge, and mutual responsibility and agreement regarding decisions related to treatment. Accumulated evidence from quantitative research, descriptive accounts, qualitative studies and trials of psychosocial interventions indicates that efficacious treatment alliances have a positive influence on adherence in BD. Then again, research on the alliance-adherence link in BD lags behind the existing literature on the subject in other medical and psychiatric conditions in terms of the size and quality of the evidence, the consistency of its findings and clarity about underlying processes mediating this link. Nevertheless, the elements of an effective alliance which could have a positive impact on adherence in BD are reasonably clear and include PCC, collaborative relationships, SDM, open communication, trust, support, and stability and continuity of the relationship. Therefore, clinicians involved in the care of BD would do well to follow these principles and improve their interpersonal and communication skills in order to build productive alliances with their patients. This could go a long way in confronting the ubiquitous problem of non-adherence in BD. The role of future research in firmly establishing the alliance-adherence connection and uncovering the processes underlying this association will also be vital in devising effective ways to manage non-adherence in BD.

Identifying clinical net benefit of psychotropic medication use with latent variable techniques: Evidence from Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

BACKGROUND

Poor medication adherence is common among individuals with Bipolar Disorder (BD). Understanding the sources of heterogeneity in clinical net benefit (CNB) and how it is related to psychotropic medications can provide new insight into ways to improve adherence.

METHODS

Data come from the baseline assessments of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Latent class analysis identified groups of CNB, and validity of this construct was assessed using the SF-36. Adherence was defined as taking 75% or more of medications as prescribed. Associations between CNB and adherence were tested using multiple logistic regression adjusting for sociodemographic characteristics.

RESULTS

Five classes of CNB were identified: High (24%), Moderately high (12%), Moderate (26%), Moderately low (27%) and Low (12%). Adherence to psychotropic medications did not differ across classes (71% to 75%, χ²= 3.43, p = 0.488). Medication regimens differed by class: 57% of the High CNB were taking ≤2 medications, whereas 49% of the Low CNB were taking ≥4. CNB classes had good concordance with the SF-36.

LIMITATIONS

Missing data limited measures used to define CNB. Participants' perceptions of their illness and treatment were not assessed.

CONCLUSIONS

This novel operationalization of CNB has construct validity as indicated by the SF-36. Although CNB and polypharmacy regimens are heterogeneous in this sample, adherence is similar across CNB. Studying adherent individuals, despite suboptimal CNB, may provide novel insights into aspects influencing adherence.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Relationship of insight with medication adherence and the impact on outcomes in patients with schizophrenia and bipolar disorder: results from a 1-year European outpatient observational study

BACKGROUND

Many patients with schizophrenia and bipolar disorder have impaired insight and low medication adherence. The aim of this post hoc analysis was to explore the relationship between insight and medication adherence.

METHODS

We included 903 patients with schizophrenia or bipolar disorder who participated in an observational study conducted in Europe on the outcomes of patients treated with two oral formulations of olanzapine over a 1-year period. Evaluations included Clinical Global Impression (CGI), Global Assessment of Functioning (GAF), insight (Scale to Assess Unawareness of Mental Disorder, SUMD) medication adherence (Medication Adherence Rating Scale, MARS), and therapeutic alliance (Working Alliance Inventory, WAI).

RESULTS

Medication adherence was higher in bipolar patients (mean MARS score (SD) 6.5 (2.8) versus 5.8 (2.7) in schizophrenia; p < 0.001). Patients with schizophrenia had lower insight (i.e., SUMD item 1, unawareness of mental disorder, mean (SD) of 2.5 (1.3) in schizophrenia versus 1.9 (1.2) in bipolar, p < 0.001). Better insight was associated with higher adherence (Spearman Correlation Coefficient, SCC, ranging from 0.39 to 0.49 for the three SUMD general items, p < 0.0001 in all cases). Higher insight was related to a stronger therapeutic alliance (SCC ranging from 0.38 to 0.48, p < 0.0001). A path analysis revealed a positive impact of insight on adherence and alliance and that stronger alliance was related to lower clinical severity (lower CGI score).

CONCLUSION

Insight and adherence were found to be closely related. Insight impacts on the therapeutic alliance with mental health professionals. These factors are associated to treatment outcomes.