Adherence to maintenance-phase antidepressant medication as a function of patient beliefs about medication

Reliability and validity of the Turkish version of the medication practical barriers to adherence questionnaire in patients with chronic diseases

PURPOSE

The aim of this study was to evaluate the validity and reliability of the Turkish version of the Medication Practical Barriers to Adherence Questionnaire (MPRAQ-TR).

METHODS

This is a validation study conducted between August 2022 and March 2023 in the ambulatory services of a secondary care private hospital located in Istanbul, Türkiye, among patients (18 years of age and older) with chronic diseases. After the Turkish translation and cultural adaptation of the MPRAQ, and a pilot think-aloud study, the following psychometric properties were assessed: internal consistency by calculating the Cronbach's alpha coefficient, 2-week test-retest reliability, convergent validity by calculating Spearman's rank correlation between the MPRAQ-TR and the Turkish version of Medication Adherence Report Scale (MARS), and predictive validity by evaluating the association between the MPRAQ-TR score and nonadherence to medications.

RESULTS

Among the 380 patients (response rate = 89.6%), 72.1% were nonadherent to their medications. The intraclass correlation coefficient was 0.99 for MPRAQ-TR scores (95% CI, 0.98-0.99; p < 0.001). The Cronbach's alpha of the MPRAQ-TR was 0.853. There was a moderate negative correlation between the scores on the MARS and the MPRAQ-TR (Spearman's rho = - 0.525; p < 0.01), supporting the convergent validity of the MPRAQ-TR. In the univariate analysis, the total score of MPRAQ-TR was associated with increased odds of nonadherence to medications (p < 0.01).

CONCLUSION

MPRAQ-TR shows good psychometric properties and can be used to evaluate the practical adherence barriers of patients with chronic diseases.

Intervention for a correct medication list and medication use in older adults: a non-randomised feasibility study among inpatients and residents during care transitions

BACKGROUND

Medication discrepancies in care transitions and medication non-adherence are problematic. Few interventions consider the entire process, from the hospital to the patient's medication use at home.

AIM

In preparation for randomised controlled trials (RCTs), this study aimed (1) to investigate the feasibility of recruitment and retention of patients, and data collection to reduce medication discrepancies at discharge and improve medication adherence, and (2) to explore the outcomes of the interventions.

METHOD

Participants were recruited from a hospital and a residential area. Hospital patients participated in a pharmacist-led intervention to establish a correct medication list upon discharge and a follow-up interview two weeks post-discharge. All participants received a person-centred adherence intervention for three to six months. Discrepancies in the medication lists, the Beliefs about Medicines Questionnaire (BMQ-S), and the Medication Adherence Report Scale (MARS-5) were assessed.

RESULTS

Of 87 asked to participate, 35 were included, and 12 completed the study. Identifying discrepancies, discussing discrepancies with physicians, and performing follow-up interviews were possible. Conducting the adherence intervention was also possible using individual health plans for medication use. Among the seven hospital patients, 24 discrepancies were found. Discharging physicians agreed that all discrepancies were errors, but only ten were corrected in the discharge information. Ten participants decreased their total BMQ-S concern scores, and seven increased their total MARS-5 scores.

CONCLUSION

Based on this study, conducting the two RCTs separately may increase the inclusion rate. Data collection was feasible. Both interventions were feasible in many aspects but need to be optimised in upcoming RCTs.

Medication self-management in predominantly African American and Caribbean American people with epilepsy: The role of medication beliefs and epilepsy knowledge

INTRODUCTION

Suboptimal medication adherence is common in people with epilepsy (PWE) and disproportionally prevalent among racially/ethnically diverse patients. Understanding reasons and risks of suboptimal adherence is critical to developing interventions that reduce negative health outcomes. This cross-sectional study characterized common barriers to medication self-management, prevalence of negative medication beliefs, and gaps in epilepsy knowledge among predominantly African American and Caribbean American PWE and examined their interrelationships.

MATERIALS AND METHODS

Sixty-three PWE (Age = 42.1 ± 13.2; 60% female; 79% Black; 19% Hispanic/Latino) completed validated self-report questionnaires about medication self-management, medication beliefs, and epilepsy knowledge. Correlations and t-tests examined interrelationships.

RESULTS

Four barriers to medication self-management were common, including not taking antiseizure medications at the same time every day, forgetting doses, not planning refills before running out, and spreading out doses when running low. More than half the sample believed medications were overused by prescribers. Nearly one-third believed medications were harmful, and nearly a quarter believed their antiseizure medications were minimally necessary with almost half reporting elevated concerns about negative consequences of antiseizure medications. Poorer medication self-management was associated with stronger beliefs that medications in general are harmful/overused by prescribers. Individuals who were "accepting" of their antiseizure medications (i.e., high perceived necessity, low concerns) were less likely to spread out time between doses when running low compared to non-accepting counterparts. Knowledge gaps related to the cause of seizures/epilepsy, chronicity of epilepsy treatment, and seizure semiology/diagnosis were common. Nevertheless, epilepsy knowledge was unrelated to medication self-management and medication beliefs.

CONCLUSIONS

In these PWE, the most prevalent reasons for suboptimal medication self-management were behaviorally mediated and potentially modifiable. Negative medication beliefs and misconceptions about epilepsy and its treatment were common. Results further suggest that interventions addressing negative medication beliefs will be more effective than knowledge-based psychoeducation alone to improve medication self-management in this patient population.

Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review

BACKGROUND

Mental illness and medication safety are key priorities for healthcare systems around the world. Despite most patients with mental illness being treated exclusively in primary care, our understanding of medication safety challenges in this setting is fragmented.

METHOD

Six electronic databases were searched between January 2000-January 2023. Google Scholar and reference lists of relevant/included studies were also screened for studies. Included studies reported data on epidemiology, aetiology, or interventions related to medication safety for patients with mental illness in primary care. Medication safety challenges were defined using the drug-related problems (DRPs) categorisation.

RESULTS

Seventy-nine studies were included with 77 (97.5%) reporting on epidemiology, 25 (31.6%) on aetiology, and 18 (22.8%) evaluated an intervention. Studies most commonly (33/79, 41.8%) originated from the United States of America (USA) with the most investigated DRP being non-adherence (62/79, 78.5%). General practice was the most common study setting (31/79, 39.2%) and patients with depression were a common focus (48/79, 60.8%). Aetiological data was presented as either causal (15/25, 60.0%) or as risk factors (10/25, 40.0%). Prescriber-related risk factors/causes were reported in 8/25 (32.0%) studies and patient-related risk factors/causes in 23/25 (92.0%) studies. Interventions to improve adherence rates (11/18, 61.1%) were the most evaluated. Specialist pharmacists provided the majority of interventions (10/18, 55.6%) with eight of these studies involving a medication review/monitoring service. All 18 interventions reported positive improvements on some medication safety outcomes but 6/18 reported little difference between groups for certain medication safety measures.

CONCLUSION

Patients with mental illness are at risk of a variety of DRPs in primary care. However, to date, available research exploring DRPs has focused attention on non-adherence and potential prescribing safety issues in older patients with dementia. Our findings highlight the need for further research on the causes of preventable medication incidents and targeted interventions to improve medication safety for patients with mental illness in primary care.

Patients' perceptions of self-administered dosing to opioid agonist treatment and other changes during the COVID-19 pandemic: a qualitative study

OBJECTIVES

During the COVID-19 pandemic, addiction treatment services received official guidance asking them to limit face-to-face contact with patients and to prescribe opioid agonist treatment (OAT) medication flexibly. With the aim for most patients to receive take-home supplies for self-administration rather than attendance for observed daily dosing.

DESIGN

This was a theory-driven, clinically applied qualitative study, with data for thematic analysis collected by semi-structured, audio-recorded, telephone interviews.

PARTICIPANTS

Twenty-seven adults (aged ≥18 years) enrolled in sublingual (tablet) buprenorphine and oral (liquid) methadone OAT.

SETTING

Community addictions centre in the London Borough of Lambeth operated by South London and Maudsley NHS Trust.

RESULTS

Three major themes were identified: (1) dissatisfaction and perceived stigma with OAT medication dispensing arrangements before the pandemic; (2) positive adaptations in response to COVID-19 by services; (3) participants recommended that, according to preference and evidence of adherence, OAT should be personalised to offer increasing medication supplies for self-administration from as early as 7 days after commencement of maintenance prescribing.

CONCLUSIONS

In an applied qualitative study of patients enrolled in OAT during the COVID-19 pandemic, participants endorsed their opportunity to take medication themselves at home and with virtual addiction support. Most patients described a preference for self-administration with increased dispensing supplies, from as early as 7 days into maintenance treatment, if they could demonstrate adherence to their prescription.

Methylphenidate augmentation of escitalopram to enhance adherence to antidepressant treatment: a pilot randomized controlled trial

BACKGROUND

Adherence to treatment, i.e. the extent to which a patient's therapeutic engagement coincides with the prescribed treatment, is among the most important problems in mental health care. The current study investigated the influence of pairing an acute positive reinforcing dopaminergic/noradrenergic effect (methylphenidate, MPH) with a standard antidepressant on the rates of adherence to medication treatment. The primary objective of this study was to determine whether MPH + escitalopram resulted in higher rates of medication adherence relative to placebo + escitalopram.

METHODS

Twenty participants with moderate to severe depression were 1-1 randomized to either (1) 5 mg MPH + 10 mg escitalopram or (2) placebo + 10 mg escitalopram with the possibility for a dose increase at 4 weeks. A Bayesian analysis was conducted to evaluate the outcomes.

RESULTS

First, neither percent Pill count nor Medication Electronic Monitoring System adherence showed that MPH was superior to placebo. In fact, placebo showed slightly higher adherence rates on the primary (7.82% better than MPH) and secondary (7.07% better than MPH) outcomes. There was a less than 25% chance of MPH augmentation showing at least as good or better adherence than placebo. Second, both groups showed a significant effect of treatment on the QIDS-SR with a median effect of an 8.6-point score reduction. Third, neither subjective measures of adherence attitudes nor socio-demographic covariates had a significant influence on the primary or secondary outcome variables.

CONCLUSIONS

These data do not support the use of MPH to increase adherence to antidepressant medication in individuals with moderate to severe depression. CLINICALTRIALS.

GOV IDENTIFIER

NCT03388164 , registered on 01/02/2018.

van Onzenoort H, J.H.M. van Laarhoven K, Bredie SJ, van Dulmen S. Identification of Cardiovascular Patient Groups at Risk for Poor Medication Adherence: A Cluster Analysis

BACKGROUND

Poor medication adherence limits the secondary prevention of cardiovascular diseases (CVDs) and leads to increased morbidity, mortality, and costs. Identifying groups of patients at risk of poor adherence behavior could enable an intervention to be developed and target patients appropriately.

OBJECTIVE

The first aim of this study was to identify homogeneous subgroups of cardiovascular outpatients based on their cardiovascular risk factors. Subsequently, differences in medication adherence between these groups were examined.

METHODS

In this retrospective, observational study, patients with an established CVD were included. Well-known cardiovascular risk factors such as smoking, diet, exercise, blood lipid levels, blood pressure, and body mass index were collected. To identify patient subgroups, a 2-step cluster analytic procedure was performed. Differences between the groups on medication adherence were determined on the outcome of the Modified Morisky Scale. Data collection took place between October 2011 and January 2013.

RESULTS

Cardiovascular risk factors of 530 patients were included in the cluster analysis. Three groups were identified. Compared with other clusters (clusters 1 and 2), cluster 3 contained significantly fewer patients who could be classified as highly adherent and more patients classified as medium adherent (23% and 57%, respectively; P = .024). This group was characterized by a younger age (53% were <55 years old) and using a relatively low number of different medications (41% used <4 different medications). Besides, in this subgroup the most smokers (37%), unhealthy alcohol users (27%), and patients with unhealthy eating habits (14%) were present.

CONCLUSION

This study showed that cardiovascular patients who are relatively young and have an unhealthy lifestyle are at risk for nonadherent behavior.

Factors Associated with Antidepressant Medication Non-adherence

Medication non-adherence is one of the major problems in treating patients with depression. Non-adherence results in an increased risk of relapse and reduced quality of life. The objective of this review was to review and summarize studies that focused on the factors associated with antidepressant medication non-adherence in patients with depression. Literature searches were performed using PubMed/Medline and Google Scholar. The search was limited to articles published in the English language in peer-reviewed journals between January 2000 and December 2019. Studies that analyzed factors of non-compliance in patients with depressive disorders were included in the review. Patient-related factors such as forgetfulness, comorbidities, and misconceptions about the disease and medication, medication-related factors, polypharmacy, side effects, pill burden and cost, healthcare system-related factors, including physician-patient interactions, sociocultural factors such religious and cultural beliefs and stigma, and logistic factors were found to be the major factors associated with antidepressant non-adherence. Efforts should be made to increase patient adherence to antidepressants by strengthening physician-patient relationships, simplifying medication regimens, and rectifying myths and beliefs held by patients with scientific information and explanations.

Psychotropic medicine beliefs, side effects and adherence in schizophrenia: a patient-caregiver dyad perspective

Background Medication adherence is essential in the management of schizophrenia. Yet poor treatment uptake has negative consequences on patients and their primary caregivers. Objective To examine the association among beliefs about psychotropic medications, side effects and adherence from a patient-caregiver dyad perspective. Setting This study was conducted in a public psychiatric hospital setting in Accra, Ghana. Methods A cross-sectional study was conducted among 121 patient-caregiver dyads using an interviewer-administered data collection approach.Main outcome measure Beliefs about medicines, side-effects and medication adherence. Results The patient and caregiver-reported level of medication adherence was 28.1 %. Using the Kappa index, the level of agreement between the responses of patients and their caregivers ranged from slight to moderate. Both patients and caregivers rated necessity higher than concern (patients: 1.67 ± 0.84, caregiver: 1.79 ± 0.96). Significant positive relations between specific-necessity, necessity-concerns differential and medication adherence were recorded while specific-concern, general harm and side-effects correlated negatively with medication adherence from the dyad. The odds of adhering to medications increased by 58 and 64 % for each unit increase in specific-necessity and general overuse scores respectively. However, a unit increase in specific-concern score and high side-effects scores were associated with lower odds of adherence. Conclusions This study highlights the need for patient-caregiver collaborations in decision-making relating to medication adherence in schizophrenia. Thus, in clinical practice, there is the need to recognize that caregivers are essential partners, and patient-caregiver views about psychotropic medications are critical in enhancing adherence for positive mental health outcomes.

How Public Trust in Health Care Can Shape Patient Overconsumption in Health Systems? The Missing Links

Overconsumption of health care is an ever-present and complex problem in health systems. It is especially significant in countries in transition that assign relatively small budgets to health care. In these circumstances, trust in the health system and its institutions is of utmost importance. Many researchers have studied interpersonal trust. Relatively less attention, however, has been paid to public trust in health systems and its impact on overconsumption. Therefore, this paper seeks to identify and examine the link between public trust and the moral hazard experienced by the patient with regard to health care consumption. Moreover, it explores the mediating role of patient satisfaction and patient non-adherence. For these purposes, quantitative research was conducted based on a representative sample of patients in Poland. Interesting findings were made on the issues examined. Patients were shown not to overconsume health care if they trusted the system and were satisfied with their doctor-patient relationship. On the other hand, nonadherence to medical recommendations was shown to increase overuse of medical services. The present study contributes to the existing knowledge by identifying phenomena on the macro (public trust in health care) and micro (patient satisfaction and non-adherence) scales that modify patient behavior with regard to health care consumption. Our results also provide valuable knowledge for health system policymakers. They can be of benefit in developing communication plans at different levels of local government.

The Shared Decision-Making Process in the Pharmacological Management of Depression

Shared decision making (SDM) is a model of interaction between doctors and patients in which both actors contribute to the medical decision-making process. There is an international consensus across medicine about the importance of SDM interventions, which have raised great interest in mental healthcare over the last decade. Yet SDM is not widely adopted, particularly in the field of psychiatry. The purpose of the present article is to examine, from a patient and physician perspective, the importance of SDM in the management of healthcare with a focus on mental health; it reviews the enablers and barriers (and how to overcome them) to implementing a SDM process in psychiatric practice. SDM models have been developed recently for involving patients with depression in the decision-making process, which could result in augmenting the proportion of patients who adhere to their antidepressant or other treatments for a duration that complies with the current recommendations. To implement this approach, more physicians need training in the SDM approach and access to appropriate tools that help engage in collaborative deliberation, and practice generally needs to be reorganized around the principles of patient engagement.

Understanding barriers to prescription retrieval and attitudes toward mental health medications at a university student health services pharmacy

OBJECTIVES

To describe barriers affecting college students' ability to retrieve prescription medications for mental health conditions from a community pharmacy embedded within a student health center on a university campus and then describe beliefs and attitudes toward the use of those medications.

METHODS

We conducted a cross-sectional study of college students who were prescribed a medication(s) for a mental health condition(s) and left the medication(s) unclaimed at the pharmacy for at least 5 days. Eligible participants were identified through routine reminder telephone calls and then provided a link to an online survey via e-mail. The survey collected information on demographics, prescription retrieval barriers, and medication beliefs and attitudes using 2 validated questionnaires. Data were summarized using descriptive statistics and scoring methods specific to the validated questionnaires.

RESULTS

A total of 83 e-mails were distributed with 46 usable responses received (55.4% response rate). Participants were undergraduate students (n = 38, 82.6%) and most frequently prescribed a medication(s) for depression (n = 21, 45.7%) or anxiety (n = 16, 34.8%). Forgetting to pick up their medication was the most commonly cited reason for prescription nonretrieval (n = 32, 69.6%) followed by limited pharmacy hours (n = 21, 45.7%). Participants generally viewed the necessity of their medication(s) as outweighing their concerns about their medication(s), and they generally viewed themselves as medication adherent.

CONCLUSIONS

University students taking medications for mental health conditions identified forgetfulness and limited pharmacy hours as the most common reasons for not retrieving prescriptions. Students generally viewed their medication(s) as necessary and themselves as medication adherent, suggesting that attitudes and beliefs may play a smaller role in medication use behaviors in this population. Future research is needed to develop and evaluate interventions that improve medication adherence in college students, potentially focused on reminder-based interventions.

The 'Necessity-Concerns Framework' as a means of understanding non-adherence by applying polynomial regression in three chronic conditions

OBJECTIVE

The 'Necessity-Concerns Framework' is an important framework which can support healthcare professionals in targeting patients' medication beliefs and decisions on adherence. Our aim was to determine how the interdependence of 'necessity' and 'concerns' beliefs for medication adherence compares across three chronic conditions.

METHODS

Patients diagnosed with asthma, cardiovascular conditions or diabetes attending out-patient clinics completed a self-administered questionnaire. The questionnaire gathered information regarding demographics, medication adherence using the 'Tool for Adherence Behaviour Screening', presence of unused medication in households and medication beliefs using the 'Beliefs about Medicines Questionnaire-Specific'. Polynomial regression was applied to determine the multidimensional interdependence of 'necessity' and 'concerns' beliefs for adherence. P-values ≤ 0.05 were taken to be significant.

RESULTS

Confirmatory polynomial regression rejected the differential score model in all three groups. For each condition, exploratory polynomial regression found that linear terms indicated the best fitting model for predicting adherence. In all groups, adherence increased as necessity beliefs increased and concerns decreased. Patients suffering from cardiovascular conditions and diabetes with low necessity and low concerns beliefs reported higher medication adherence compared to those with high necessity and high concerns beliefs.

DISCUSSION

Alleviating patients' concerns can enhance medication adherence and potentially curb the issue of medication wastage.

Affordability, availability and tolerability of anti-seizure medications are better predictors of adherence than beliefs: Changing paradigms from a low resource setting

OBJECTIVES

Anti-seizure medication (ASM) non-adherence contributes to treatment gap and increases mortality and morbidity associated with epilepsy. Beliefs about medications are considered better predictors of ASM non-adherence than clinico-demographic factors. We aimed to look into ASM non-adherence rates among adults with epilepsy (AWE), identify the contributing barriers and determine whether medication beliefs were more powerful predictors than clinico-demographic factors.

METHODS

This was a cross-sectional study of AWE receiving ASMs. Participants (n = 304) were assessed by validated questionnaires, for non-adherence (8-item Morisky Medication Adherence Scale) and perceptions of ASMs (Beliefs about Medicines Questionnaire) along with clinico-demographic details.

RESULTS

Our group with high literacy and low-income had a high non-adherence rate (55 %) despite having positive beliefs (Mean necessity-concern differential [NCD] = 2.86). Among the beliefs, ASM non-adherence was significantly associated with ASM-concern (t = 4.23, p < 0.001) and NCD (t = -4.11, p < 0.001). Stepwise multiple linear regression analysis showed that non-adherence was significantly associated with per-capita income (β -0.215, p < 0.001), ASM side effects (β 0.177, p = 0.001), high seizure frequency (β 0.167, p = 0.002), ASM availability (β -0.151, p = 0.004), ASM costs (β -0.134, p = 0.013 and NCD (β -0.184, p = 0.001). NCD accounted for 2.9 % of the variance in non-adherence whereas the other clinico-demographic variables together accounted for 14.6 %.

CONCLUSION

We describe a paradigm shift in AWE with high non-adherence to ASMs, wherein clinico-demographic variables emerge as better predictors of non-adherence than beliefs. High literacy facilitates the perception of need for ASMs whereas costs and side effects hamper adherence.

The Role of Medication Beliefs on Medication Adherence in Middle Eastern Refugees and Migrants Diagnosed with Hypertension in Australia

PURPOSE

The study assessed the association between medication beliefs and adherence in Middle Eastern refugees and migrants in Australia, and also examined differences between the two groups regarding beliefs and adherence to medication.

PATIENTS AND METHODS

A total of 319 Middle Eastern refugees and migrants with hypertension were approached via various social groups in Australia and asked to complete Arabic versions of the Beliefs about Medicine Questionnaire (BMQ) and the Medication Adherence Questionnaire. BMQ scores (necessity and concerns scales) were classified as "accepting", "indifferent", "ambivalent" or "skeptical". Multiple mediation modelling was applied to examine the role of necessity and concerns scales as mediators between migration status and medication adherence.

RESULTS

There were significant associations between medication adherence and medication beliefs scores (necessity and concerns scales) (p=0.0001). Necessity and concern were mediators in the relationship between migration status and medication adherence. Significant differences were found between refugees and migrants for medication adherence and medication beliefs. Refugees were likely to have less necessity, and more concern beliefs than migrants, and were also less likely to adhere to medications. Almost 30% of refugees could be classified as skeptical and 40% as ambivalent. In contrast, 50% of migrants had accepting beliefs, and around 35% held ambivalent beliefs. Refugees and migrants with "accepting" beliefs reported the highest adherence to medication and those holding "skeptical" beliefs reported the lowest adherence.

CONCLUSION

Medication beliefs are potentially modifiable and are reasonable targets for clinical interventions designed to improve medication adherence. Understanding these beliefs and the likely differences between refugees and migrants is crucial to provide specific and targeted advice to each group independently in order to improve medication adherence and overall health.

Multi-measure assessment of adherence to antiretroviral therapy among children under five years living with HIV in Jinja, Uganda

Background

Adherence to Antiretroviral Therapy (ART) is required to achieve HIV viral load suppression. However, children under 5 years in Jinja, Uganda, had been shown to have low HIV suppression rates. This study aimed to determine the level of ART non-adherence among these children and the associated factors.

Methods

Data for the cross-sectional study was collected from April to July 2019, from caregivers of 206 children under 5 years living with HIV who were attending health facilities in Jinja and had been on ART for at least 3 months. Non-adherence was measured using a Visual Analog Scale that assessed both dosing and timing non-adherence, and by determining the Proportion of Days Covered by the medication. A questionnaire administered to the caregivers was used to collect the data, together with medical record review. A child was only considered adherent if they had adherence greater than 95% on all the measures. The data was analysed using Modified Poisson Regression, taking a p-value less than 0.05 as statistically significant.

Results

Of the 206 children, 73.8% were older than 2 years, and 52.9% were female. Likewise, the majority of caregivers were female (93.7%). Using the combined adherence measure, 57.3% of the children were categorised as non-adherent. School/day-care attendance, Prevalence Ratio (PR) = 1.25 (p = 0.042), the caregiver having higher than a primary school education, PR = 0.72 (p = 0.044) and satisfaction with the quality of service at the health facility, PR = 0.97 (p < 0.001) were associated with non-adherence. Household food insecurity was also associated with non-adherence: PR = 1.55 (p = 0.011) for mild food insecurity, PR = 1.75 (p = 0.001) for moderate insecurity and PR = 1.48 (p = 0.015) for severe food insecurity.

Conclusions

Children under 5 years in Jinja had a high level of ART non-adherence. It is important to engage schools to support adherence among children living with HIV. Addressing household food insecurity and improving the quality of paediatric ART services would also reduce the barriers to optimal adherence.

Self-reported medication adherence tools in cardiovascular disease: protocol for a systematic review of measurement properties

OBJECTIVE

The aim of this review is to identify high-quality, self-reported medication adherence tools for adults with cardiovascular disease to improve health outcomes.

INTRODUCTION

Medication adherence is a complex concept affected by multiple factors and positively associated with clinical outcomes. Poor adherence to cardiovascular medications is a hindrance to the effective management of cardiovascular disease, leading to poor disease prognosis or increased risk of death. Valid and reliable measurement is crucial to identify patients with poor adherence, preferably before an adverse outcome occurs.

INCLUSION CRITERIA

This review will consider studies that include adults, aged 18 years and over, with a diagnosis of cardiovascular disease. The construct of medication adherence has three phases: initiation, implementation and discontinuation. Included tools need to measure at least one of these phases. The review will consider studies of any study design that report on the measurement properties of self-reported medication adherence tools among adults with cardiovascular disease.

METHODS

The following databases will be searched from inception to present: PubMed, MEDLINE, CINAHL, ProQuest Health and Medicine, Cochrane Library, PsycINFO, Scopus, Embase and Web of Science. Articles published in any language will be included, with no date limit. Data extraction will be performed by one reviewer and cross-checked by another reviewer. Data from the included studies will be synthesized using tables for the quality of methods, and measurement property results.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019124291.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017067436.

Self-Report for Measuring and Predicting Medication Adherence: Experts' Experience in Predicting Adherence in Stable Psychiatric Outpatients and in Pharmacokinetics

THE PROBLEM

Poor adherence to appropriately prescribed medication is a global challenge for psychiatrists.

PRIOR STUDIES

Measuring adherence is complicated. In our recent three-country naturalistic study including more than 1000 patients and their adherence to multiple medication prescriptions at the same time, patients' self-report of adherence to each specific drug was the only practical option for measuring adherence. Systematic literature reviews provide inconsistent results for sociodemographic, clinical and medication variables as predictors of adherence to psychiatric drugs. Our studies over the last 10 years in relatively stable psychiatric outpatients have shown that some self-reported health beliefs had consistent, strong effects and a better predictive role. Three dimensions of these health beliefs are characteristics of the individual: 1) attitudes toward psychiatric medication such as pharmacophobia (fear of taking drugs or medicines), 2) health locus of control (the belief patients have about who or what agent determines the state of their health), 3) psychological reactance (an emotional reaction in direct contradiction to rules or regulations that threaten or suppress certain freedoms in behavior). They can be measured by the Patient Health Beliefs Questionnaire on Psychiatric Treatment. The attitude toward each specific medication can be measured by the necessity-concern framework and summarized as the presence or absence of skepticism about that drug. After 25 years conducting pharmacokinetic studies in psychiatric drugs, particularly antipsychotics, we have limited understanding of how to use blood levels to predict the effects of non-adherence or to establish it.

EXPERT OPINION ON FUTURE STUDIES

Future studies to predict adherence should include the inpatient setting and explore insight. Studying the pharmacokinetics associated with non-adherence in each psychiatric drug is a major challenge. Medication adherence is a complex and dynamic process changing over time in the same patient. Personalizing adherence using psychological or pharmacological variables are in their initial stages.

The necessity-concern framework in the assessment of treatment adherence of psychiatric patients and the role of polypharmacy in a Spanish sample

OBJECTIVE

This study compares three measures (necessity and concern scores, the necessity-concern differential, and a skeptical attitude vs. three other attitudes) for studying the relationship between the necessity-concern framework and treatment adherence after considering the number of prescribed drugs.

METHODS

The sample included 588 consecutive adult psychiatric outpatients in the Canary Islands, Spain. The necessity-concern framework was assessed using a specific subscale of the Beliefs about Medicines Questionnaire. Adherence (yes/no) to 1,101 prescribed psychiatric drugs was assessed using the Sidorkiewicz adherence tool.

RESULTS

In the three logistic regression models including 1,101 drugs, with adherence as the dependent variable, the highly significant odds ratios (ORs) and their 95% confidence intervals (CIs) were (a) OR = 1.57 (CI = 1.37-1.79) for necessity and OR = 0.747 (CI = 0.660-0.847) for concern; (b) OR = 1.44 (CI = 1.32-1.58) for the necessity-concern differential; and (c) OR = 0.452 (CI = 0.343-0.597) for a skeptical attitude (yes/no), defined as low necessity and high concern. In patients taking five or six drugs, adherence was associated with extremely high/low ORs for necessity, concern, and the differential.

CONCLUSION

If replicated, our results suggest clinicians need to pay careful attention to each drug in each patient taking five or six drugs, emphasize necessity, and listen carefully to patient concerns.

Patient-Reported Outcome Measures (PROMs) to Support Adherence to Falls Prevention Clinic Recommendations: A Qualitative Study

PURPOSE

We examined how patient-reported outcome measures (PROMs) support patients' adherence to fall prevention recommendations in a novel primary care setting - the Falls Prevention Clinic.

PATIENTS AND METHODS

Using a patient-oriented qualitative study design, we recruited patient partners to our study team to assist in developing focus group prompts. A trained facilitator conducted five semi-structured interviews with a total of 21 Falls Prevention Clinic participants. A trained facilitator prompted participants about: their views on the EuroQol 5 domain - 5 level (EQ-5D-5L) PROM, their preferences for PROM administration and feedback, the presentation of PROM questionnaire data, the use of comparative data and the EQ-5D-5L in improving adherence to recommendations, and other information they would need to improve adherence. Participants' responses were coded according to three stages of qualitative analysis: open, axial and selective coding using an iterative and comparative approach.

RESULTS

"Opportunity" and "Development" emerged as higher-level themes for the participants' perspectives on how the EQ-5D-5L may be helpful for their appointments. "Frequency" described how often the participants believed the EQ-5D-5L should be administered and feedback provided. "Challenges", "Benefits", "Patients' Understanding", "Relevance of Data", and "Usefulness of Data" provided insight on how PROMs data presentation was viewed by patients. "Performance", "Resources", "Knowledge", "Role in Behaviour Change" highlighted the participants' ideas for the role of the EQ-5D-5L and additional information in supporting their adherence to falls prevention recommendations. Participants emphasized that patients would value further support information to facilitate their adherence.

CONCLUSION

This patient-oriented qualitative study, among individuals at high risk of future falls, sheds light on the importance of timely, understandable feedback, integrated with other clinical feedback in supporting adherence.

Men's views of antidepressant treatment for depression, and their implications for community pharmacy practice

BACKGROUND

Men with depression can express and navigate their condition differently to women. Understanding this population's needs, and experiences, can help healthcare professionals better support these patients. There is a lack of knowledge in this area, and no studies have explored men's depression in the context of community pharmacy.

OBJECTIVES

Explore views of men around their medication for the treatment of depression and the role of community pharmacy in their treatment.

SETTING

United Kingdom (UK) primary care.

METHOD

Semi-structured in-depth interviews were conducted. Eligible participants were male, aged 18-65 years, and treating depression with antidepressants. Participants were recruited through 5 UK pharmacies (via the pharmacist or poster recruitment) and a UK University (poster recruitment). A thematic approach was used for analysis.

RESULTS

14 men aged 26-61 years, predominantly of white ethnicity were interviewed. Key themes were found. The theme 'Antidepressant's attributions to benefits' highlighted all men noticed benefits when taking antidepressants, but held uncertainty on what extent their antidepressants caused this. The themes 'Views of pharmacist's role influences engagement', and 'Influence of cognitive state upon healthcare interactions' demonstrated men were not inclined to discuss concerns with the community pharmacist. These men didn't see this as the pharmacist's role, nor had these men given cognitive space to evaluate their treatment beliefs or information needs. Yet the theme 'Reflection of support and information needs' shows men did have unmet information and support needs. This also links into the 'Hegemonic Masculinity and taking antidepressants' theme, where taking antidepressants could challenge ones masculinity.

CONCLUSION

Community pharmacists should create opportunities for men to engage in conversations around their antidepressants and wider support. Men, as a requisite for engagement, will need to see such interactions as within the community pharmacists' remit, and as part of a collaborative healthcare system.

Evidence-based practice: a comparison of International Clinical Practice Guidelines and current research on physical activity for mild to moderate depression

In 2016, the U.S. Preventive Services Task Force recommended routine depression screening for individuals aged 13 and above. Questionnaire-based screening will likely increase treatment in patients with milder symptoms. Although professional groups who develop clinical practice guidelines recognize the importance of considering the risks and benefits of interventions, no official mandate exists for a stepped-care approach. Physical activity warrants increased consideration in guidelines, given the optimal risk/benefit profile and the increasing evidence of efficacy for the treatment and prevention of depression. The aim of the current study was to evaluate clinical practice guidelines for the treatment of major depressive disorder, specifically the recommendation of physical activity and adherence to a stepped-care approach. Authors searched three databases to identify treatment guidelines for depression. Guidelines were reviewed on the following domains regarding recommendation of physical activity: (a) front-line intervention, (b) explicit but not front-line recommendation, (c) inexplicit recommendation, (d) no mention, (e) adherence to a stepped-care approach, and (f) presentation of empirical support for their recommendation. Seventeen guidelines met inclusion criteria. Four guidelines recommended physical activity as a front-line intervention, two did not mention physical activity, eleven made some mention of physical activity, seven presented evidence to support their recommendation, and seven employed a stepped-care approach. The majority of guidelines did not use a stepped-care approach and varied greatly in their inclusion of physical activity as a recommended intervention for mild to moderate depression. Implications for practice, research, and policy are discussed.

A nurse-based intervention for improving medication adherence in cardiovascular patients: an evaluation of a randomized controlled trial

Background: Poor medication adherence is a limitation in the secondary prevention of cardiovascular diseases (CVDs) and leads to increased morbidity, mortality, and costs. Purpose: To examine the process and effect of a nurse-led, web-based intervention based on behavioral change strategies to improve medication adherence in patients with CVD. Patients and methods: In this single-center, prospective, controlled clinical trial, cardiovascular patients were assigned to usual care, usual care plus a personalized website, or usual care plus a personalized website and personal consultations. Primary outcome was the level of adherence to cardiovascular medication. Data collection occurred between October 2011 and January 2015. Results: In total, 419 patients were randomized. Just 77 patients logged on the website and half of the invited patients attended the group consultation. Due to the limited use of the website, we combined the results of usual care and the usual care plus website group in one group (usual care) and compared these with the results of the group which received the nurse intervention (intervention group). No significant difference in adherence between the usual care group and the intervention group was observed. The adherence level in the usual care group was 93%, compared to 89% in the intervention group (p=0.08). 29% (usual care) and 31% (intervention group) of the patients showed a low adherence according to the Modified Morisky Scale® (p-value=0.94). The mean necessity concern differential was 3.8 with no differences between the two studied groups (mean 3.8 vs mean 3.9, p-value =0.86). Conclusion: Our intervention program did not show an effect. This could indicate that structured usual care provided to all cardiovascular patients already results in high medication adherence or that shortly after a cardiovascular event adherence is high. It could also indicate that the program did not have enough impact because there was not enough compliance with the intervention protocol. Trial registration: ID number NCT01449695, approved May 2011.

Prior medication adherence of participants and non participants of a randomized controlled trial to improve patient adherence in cardiovascular risk management

Background

Poor medication adherence is a major factor in the secondary prevention of cardiovascular diseases (CVD) and contributes to increased morbidity, mortality, and costs. Interventions for improving medication adherence may have limited effects as a consequence of self selection of already highly adherent participants into clinical trials.

Methods

In this retrospective cohort study, existing levels of medication adherence were examined in self-decided participants and non-participants prior to inclusion in a randomized controlled study (RCT), evaluating the effect of an intervention to improve adherence. In addition, the non-participants were further divided into ‘responders’ and ‘non responders’. All individuals had manifest cardiovascular disease and completed a questionnaire with baseline characteristics, the Beliefs about Medicines Questionnaire (BMQ) and the Modified Morisky Scale® (MMS®) as part of a regular screening program. A logistic regression was conducted to examine the relationship between study participation willingness, adherence level and the beliefs about medication.

Results

According to the MMS® the adherence level was comparable in all groups. In both (non)-participants groups, 36% was classified as high adherent; 46% participants versus 44% non-participants were classified as medium adherent and 19% of the participants versus 20% of the non-participants were low adherent (p = 0.91. The necessity concern differential (NCD) from the BMQ was 3.8 for participants and 3.4 for non-participants (p = 0.32).

Conclusion

This study shows that adherence to medication and beliefs about medication do not differ between participants and non-participants before consenting to participate in an RCT. The study design seems not to have led to greater adherence in the study group.

Adherence to ursodeoxycholic acid therapy in patients with cholestatic and autoimmune liver disease

BACKGROUND

Ursodeoxycholic acid (UDCA) is used for treatment of cholestatic liver diseases and may improve long-term outcome. Although treatment with this hydrophilic bile acid is virtually without side effects, medication adherence might be suboptimal due to patient misconceptions, compromising clinical outcome. Our aim was to evaluate adherence to UDCA in relation to patient beliefs about medicine and to identify potential predictors of poor adherence.

METHODS

Prospective open-label study recruiting patients in treatment with UDCA from April 2016 to March 2017. Adherence was assessed both by the Sensemedic dispenser and by patient-reported adherence, during 12 weeks. Good adherence was defined as ≥ 80% intake. Quality of life (by SF-36) and beliefs about medicine (by BMQ) were also assessed.

RESULTS

A total of 75 patients were enrolled (32% primary biliary cholangitis, 31% autoimmune hepatitis, 29% primary sclerosing cholangitis and 8% other conditions). Average adherence according to the medication dispenser was 92 ± 16% (range: 17-100). Eighty-nine percent of the patients exhibited good adherence and 11% poor adherence. According to the BMQ, 42% of all patients were accepting, 50% ambivalent, 8% indifferent and 0% skeptical to UDCA treatment. Poor adherence was associated with young age (P = 0.029) and male gender (P = 0.021).

CONCLUSIONS

Despite the excellent safety profile of UDCA, still a significant number of patients are poorly adherent. Young age and male sex are associated with poor adherence. Efforts should be made to identify patients with poor adherence and to improve their compliance to therapy.

Predicting adherence to therapy in rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis: a large cross-sectional study

Objective

This analysis explored the association of treatment adherence with beliefs about medication, patient demographic and disease characteristics and medication types in rheumatoid arthritis (RA), psoriatic arthritis (PsA) or ankylosing spondylitis (AS) to develop adherence prediction models.

Methods

The population was a subset from ALIGN, a multicountry, cross-sectional, self-administered survey study in adult patients (n=7328) with six immune-mediated inflammatory diseases who were routinely receiving systemic therapy. Instruments included Beliefs about Medicines Questionnaire (BMQ) and 4-item Morisky Medication Adherence Scale (MMAS-4^©), which was used to define adherence.

Results

A total of 3390 rheumatological patients were analysed (RA, n=1943; PsA, n=635; AS, n=812). Based on the strongest significant associations, the adherence prediction models included type of treatment, age, race (RA and AS) or disease duration (PsA) and medication beliefs (RA and PsA, BMQ-General Harm score; AS, BMQ-Specific Concerns score). The models had cross-validated areas under the receiver operating characteristic curve of 0.637 (RA), 0.641 (PsA) and 0.724 (AS). Predicted probabilities of full adherence (MMAS-4^©=4) ranged from 5% to 96%. Adherence was highest for tumour necrosis factor inhibitors versus other treatments, older patients and those with low treatment harm beliefs or concerns. Adherence was higher in white patients with RA and AS and in patients with PsA with duration of disease <9 years.

Conclusions

For the first time, simple medication adherence prediction models for patients with RA, PsA and AS are available, which may help identify patients at high risk of non-adherence to systemic therapies.

Trial registration number

ACTRN12612000977875.

Patients' attitudes to discontinuing not-indicated long-term antidepressant use: barriers and facilitators

BACKGROUND

Long-term antidepressant use has increased exponentially, though this is not always according to guidelines. Our previous randomized controlled trial (RCT) showed that participants using antidepressants long term without a proper indication were apprehensive to stop: only half were willing to attempt to discontinue their antidepressant use. The objective of this study was to explore participants' barriers and facilitators for stopping long-term antidepressant use without a current proper indication.

METHODS

Semistructured interviews with participants from the intervention group of our RCT, a cluster-RCT in general practice in the Netherlands. The latter study was a stop trial with patients on long-term antidepressant use without a current indication (no psychiatric diagnosis). Participants of the intervention group of the RCT had been provided with advice to stop antidepressants. Participants of the current interview study were purposively sampled (from the intervention group of the RCT) to ensure diversity in age, sex, and intention to discontinue the antidepressant. Analysis was performed as an iterative process, based on the constant comparative method. Data collection proceeded until saturation was reached.

RESULTS

A total of 16 participants were interviewed. Fear (of recurrence, relapse, or to disturb the equilibrium) was the most important barrier; prior attempts fueled these anticipations. Also prominent as a barrier was the notion that antidepressants are necessary to counter a deficiency of serotonin. Facilitators were information on duration of usage given at the time of first prescription and confidence in a successful attempt. We found many participants struggling between barriers and facilitators to discontinue and participants not discontinuing while experiencing no barriers (ambivalence).

CONCLUSION

Fear is an important motive for patients considering discontinuation of antidepressants. Serotonin deficiency as explanation for antidepressant effectiveness promotes life-long use and hinders discontinuation of antidepressant treatment. The prospect of discontinuation at first prescription can facilitate a future discontinuation attempt. General practitioners should be aware of their patients' fears, expectations, and attributions toward antidepressant use/discontinuation, and of new developments in taper methods.

Length of time periods in treatment effect descriptions and willingness to initiate preventive therapy: a randomised survey experiment

Background

Common measures used to describe preventive treatment effects today are proportional, i.e. they compare the proportions of events in relative or absolute terms, however they are not easily interpreted from the patient’s perspective and different magnitudes do not seem to clearly discriminate between levels of effect presented to people.

Methods

In this randomised cross-sectional survey experiment, performed in a Swedish population-based sample (n = 1041, response rate 58.6%), the respondents, aged between 40 and 75 years were given information on a hypothetical preventive cardiovascular treatment. Respondents were randomised into groups in which the treatment was described as having the effect of delaying a heart attack for different periods of time (Delay of Event, DoE): 1 month, 6 months or 18 months. Respondents were thereafter asked about their willingness to initiate such therapy, as well as questions about how they valued the proposed therapy.

Results

Longer DoE:s were associated with comparatively greater willingness to initiate treatment. The proportions accepting treatment were 81, 71 and 46% when postponement was 18 months, 6 months and 1 month respectively. In adjusted binary logistic regression models the odds ratio for being willing to take therapy was 4.45 (95% CI 2.72–7.30) for a DoE of 6 months, and 6.08 (95% CI 3.61–10.23) for a DoE of 18 months compared with a DoE of 1 month. Greater belief in the necessity of medical treatment increased the odds of being willing to initiate therapy.

Conclusions

Lay people’s willingness to initiate preventive therapy was sensitive to the magnitude of the effect presented as DoE. The results indicate that DoE is a comprehensible effect measure, of potential value in shared clinical decision-making.

Patients' Perspectives of Oral and Injectable Type 2 Diabetes Medicines, Their Body Weight and Medicine-Taking Behavior in the UK: A Systematic Review and Meta-Ethnography

The aim of this review is to identify peoples' perspectives of their glucose-lowering and anti-obesity drugs in relation to diabetes and weight control and to explore how these views affect medication adherence. Theoretical perspectives associated with medicine-taking behavior are also explored. The systematic review was based on a meta-ethnography of qualitative studies identified through a search of 12 medical and social science databases and subsequent citation searches. The quality of all studies was assessed. Sixteen studies were included with data from 360 UK individuals. No relevant studies were identified which focused on anti-obesity and non-insulin injectable drugs. The review revealed that the patients' perspectives and emotional state were influenced by starting and/or changing to a new glucose-lowering medicine. These were also influenced by prior medication experience, disease perceptions and interactions with clinicians. Despite reports of positive experiences with and positive perceptions of medicines, and of participation in strategies to regain life control, medication non-adherence was common. Accepting glucose-lowering medicines impacted on the individual's perception of lifestyle changes, and it was notable that weight loss was not perceived as a strategy to support diabetes management. Synthesis revealed that more than one theory is required to explain medicine-taking behavior. New insights into the underlying factors of poor adherence and the specific practical issues identified in this review can help in the development of patient-centered interventions.

FUNDING

Diabetes UK.

Neighbourhood Material and Social Deprivation and Exposure to Antidepressant Drug Treatment: A Cohort Study Using Administrative Data

OBJECTIVE

To assess whether neighbourhood deprivation is associated with exposure to an antidepressant drug treatment (ADT) and its quality among individuals diagnosed with unipolar depression and insured by the Quebec public drug plan.

METHOD

We conducted an administrative database cohort study of adults covered by the Quebec public drug plan who were diagnosed with a new episode of unipolar depression. We assessed material and social deprivation using an area-based index. We considered exposure to an ADT as having ≥1 claim for an ADT within the 365 days following depression diagnosis. Among those exposed to ADT, ADT quality was assessed with 3 indicators: first-line recommended ADT, persistence with the ADT, and compliance with the ADT. Generalized linear models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI).

RESULTS

Of 100,432 individuals with unipolar depression, 65,436 (65%) were exposed to an ADT in the year following the diagnosis. Individuals living in the most materially deprived areas were slightly more likely to be exposed to an ADT than those living in the least deprived areas (aPR, 1.04; 95% CI, 1.03 to 1.06). The likelihoods of being exposed to a first-line ADT, persisting for the minimum recommended duration and complying with the ADT were independent of the deprivation levels.

CONCLUSIONS

Neighbourhood deprivation was not associated with ADT quality among individuals insured by the Quebec public drug plan. It might be partly attributable to the public drug plan whose goal is to provide equitable access to prescription drugs regardless of income.

The Impact of Hepatitis C Virus Direct-Acting Antivirals on Patient-Reported Outcomes: A Dutch Prospective Cohort Study

INTRODUCTION

Pegylated interferon-based therapy for hepatitis C virus (HCV) negatively impacts nutritional state and patient-reported outcomes (PROs) such as health-related quality of life (HRQL). Clinical trials with direct-acting antivirals (DAAs) report significant PRO improvement but real-world data are still scarce.

METHODS

Prospective cohort study recruiting HCV patients treated with DAAs in 2015-2016. Data at baseline, end of treatment (EOT) and 12 weeks thereafter (FU12) included: patient-reported medication adherence; SF-36; Karnofsky Performance Status; paid labour productivity; physical exercise level; nutritional state [by body mass index (BMI) and Jamar hand grip strength (HGS)] and Beliefs about Medicines Questionnaire. Potential factors predicting these PROs were evaluated with multiple regression analysis.

RESULTS

A total of 68 patients were enrolled: 85% male, median age 57 years, 80% genotype 1, 40% cirrhotics, 46% haemophilia. Both cure rate and patient-reported adherence were 97%. SF-36 Physical Component Summary did not change (43.2 ± 11.9, 44.9 ± 10.3 and 44.7 ± 10.9 at baseline, EOT and FU12, p = 0.71). In contrast, SF-36 mental component summary (MCS) decreased transiently during therapy (49.2 ± 11.9, 44.6 ± 10.3 and 49.9 ± 12.6 at baseline, EOT and FU12, p < 0.01). Concomitant ribavirin-use was the only independent predictor of decreased SF-36 MCS. BMI (25.7 ± 4.5 and 25.6 ± 4.4 at baseline and EOT, p = 0.8) and Jamar HGS (39.7 ± 13.0, 37.4 ± 11.9 and 37.9 ± 13.8 at baseline, EOT and FU12, p = 0.56) did not change.

CONCLUSION

Our study reveals concomitant ribavirin as the only independent predictor of transient decrease in SF-36 mental HRQL during DAA therapy. In contrast to interferon-based therapy, DAAs do not affect BMI or Jamar HGS.

ALIGNed on adherence: subanalysis of adherence in immune-mediated inflammatory diseases in the DACH region of the global ALIGN study

Background

Non‐adherence to medication is a challenging problem in daily clinical practice.

Objective

To assess reasons for non‐adherence in patients with chronic immune‐mediated inflammatory diseases (IMIDs) in a direct comparison including evaluation of treatment necessity and concerns.

Methods

ALIGN was a non‐interventional, multicountry, multicentre, self‐administered, cross‐sectional, epidemiologic survey study. Here, we investigate the German, Austrian and Swiss (DACH) cohort. Six hundred thirty‐one patients with different IMIDs (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, plaque psoriasis, Crohn's disease and ulcerative colitis) under systemic therapies were evaluated concerning adherence, beliefs of necessity and concerns towards treatment in patients with IMIDs.

Results

The DACH cohort had significantly different levels of adherence depending on the IMID (P < 0.05) and the type of therapy (P < 0.05). Based on the significant influence of concerns on treatment adherence (P < 0.05) and the high belief of treatment necessity, patients could be classified in four attitudinal segments, which were unequally distributed throughout various IMIDs. High concerns had a significant influence on non‐adherence, whereas necessity did not. Older age, female sex, TNFi mono‐, conventional combination and TNFi combination therapy are positively associated with adherence.

Conclusions

In the DACH region, patients are less concerned about medication and believe in the necessity of treatment. Therefore, we suggest adapting the communication in the various patient groups.

Assessing Cognitive Representations of Antidepressants: Development and Validation of the Attitudes Toward Medication–Depression Inventory

Antidepressant drugs represent the mainstay of treatment for depression; however, nonadherence is a major problem. Attitudes are predictors of long-term adherence and drive medication use. The Attitudes Toward Medication–Depression (ATM-D) Inventory was developed and tested with 131 patients in primary care settings who reported a diagnosis of depression. Content validity was assessed by experts with a 94.4% agreement on item relevancy. Exploratory factor analysis showed three factors (course of medication treatment, identity, and control) that accounted for 57% of the total variance in the final 17-item scale. The instrument demonstrated good internal consistency reliability (α = .76-.84) and test–retest reliability (α = .74-.83). Results support the construct validity and reliability of the instrument and revealed unique insights into patients’ cognitive representations of their antidepressants. This study supported that patients have cognitive representations related to depression and antidepressants that go beyond simple concerns about the effects of the medication.

Predicting rehospitalization in patients treated with antipsychotics: a prospective observational study

BACKGROUND

Prediction of rehospitalization in patients treated with antipsychotics is important for identifying patients in need of additional support to prevent hospitalization. Our aim was to identify factors that predict rehospitalization in patients treated with antipsychotics at discharge from a psychiatric hospital.

METHODS

Adult patients suffering from schizophrenia, psychotic or bipolar I disorders who had been hospitalized in a psychiatric hospital for ⩾7 days and were treated with oral antipsychotics at discharge were included. The main outcome was rehospitalization within 6 months after discharge. A prediction model for rehospitalization was constructed including: patient/disease and medication characteristics, patients' beliefs about medicines, and healthcare-professional-rated assessment for all patients. The patients were stratified by diagnosis (schizophrenia and nonschizophrenia). Area under the receiver operating characteristic curve (AUC_ROC) was also assessed.

RESULTS

A total of 87 patients were included and 33.3% of them were rehospitalized within 6 months after discharge. The variables that predicted rehospitalization were duration of hospitalization, patients' attitude towards medicine use, and healthcare-professional-rated assessment with an AUC_ROC of 0.82. Rehospitalization for patients with schizophrenia could be predicted (AUC_ROC = 0.71) by the Global Assessment of Functioning score, age, and harm score. Rehospitalization was predicted (AUC_ROC = 0.73) for nonschizophrenia patients with, for example rehospitalization predicted by the nurse.

CONCLUSIONS

Rehospitalization was predicted by a combination of variables from the patient/disease and medication characteristics, patients' attitude towards medicine use, and healthcare-professional-rated assessment. These variables can be assessed relatively easily at discharge to predict rehospitalization within 6 months.

Super Pill is Less Effective than an Ordinary Mint in Altering Subjective Psychological Feeling States within a Few Minutes

Expectations shape human behavior. Initial drug use might be associated with information-based expectations. In this study, we presumed that changes in affect and perceived physical wellbeing will be stronger after receiving an active placebo (Tic Tac mint; n = 40), than a pure placebo (inert pill; n = 40) given as a mood-enhancing "super pill." After baseline measures, participants completed a treatment-expectancy scale, ingested the mint/super pill, and attended to the effects over 3-minutes. Subsequently, they completed again the psychological tests. Expectancy scores were positive and did not differ between the groups. The pure placebo group increased in physical wellbeing but less than the active placebo group, which also showed an increase in positive affect. Negative affect decreased in both groups. The Tic Tac produced greater affective changes than the pure placebo. Since these are new findings on the ultra-short placebo effects on affect, the results might have relevance for drug-use studies.

Beliefs and behavioural intentions towards pharmacotherapy for stuttering: A survey of adults who stutter

PURPOSE

Although considerable efforts have been made to investigate the effectiveness of pharmacological treatments for stuttering, little is known about how the stuttering community perceives these treatments. This study aimed to assess and quantify beliefs regarding pharmacotherapy for adults who stutter and to establish whether behavioural intentions to undertake treatment were related to these beliefs.

METHOD

An adapted version of the Beliefs about Medicine Questionnaire was completed by adults who stutter. Participants also reported perceptions of their stuttering including its overall impact, ratings of previous speech therapy, and behavioural intentions to initiate pharmacotherapy and speech therapy in future.

RESULTS

Necessity and concern beliefs were distributed widely across the sample and in a pattern indicating a relatively balanced perception of the benefits and costs of medication prescribed specifically for stuttering. Of the study's measures, the necessity-concerns differential most strongly predicted the behavioural intention to initiate pharmacotherapy. The overall impact of stuttering predicted intentions to seek both pharmacotherapy and speech therapy. Participants reported the likelihood of pursuing pharmacotherapy and speech therapy in equal measure.

CONCLUSIONS

The theoretical model of medication representations appears to be a useful framework for understanding the beliefs of adults who stutter towards the medical treatment of their disorder. The findings of this study may be of interest to clinicians and researchers working in the field of stuttering treatment and to people who stutter considering pharmacotherapy.

Skepticism and pharmacophobia toward medication may negatively impact adherence to psychiatric medications: a comparison among outpatient samples recruited in Spain, Argentina, and Venezuela

BACKGROUND

Cultural differences in attitudes toward psychiatric medications influence medication adherence but transcultural studies are missing. The objective of this study was to investigate how attitudes and beliefs toward psychotropic medications influence treatment adherence in psychiatric outpatients in Spain, Argentina, and Venezuela.

METHODS

A cross-sectional, cross-cultural psychopharmacology study was designed to assess psychiatric outpatients' attitudes toward their prescribed medication. Patients completed the Drug Attitude Inventory - 10 Item (DAI-10), the Beliefs about Medicines Questionnaire - Specific Scale (BMQ-Specific), the Sidorkiewicz adherence tool, and sociodemographic and clinical questionnaires. The study included 1,291 adult psychiatric outpatients using 2,308 psychotropic drugs from three Spanish-speaking countries, the Canary Islands (Spain) (N=588 patients), Argentina (N=508), and Venezuela (N=195).

RESULTS

The univariate analyses showed different mean scores on the DAI-10 and the BMQ - Necessity and Concerns subscales but, on the other hand, the percentages of non-adherent and skeptical patients were relatively similar in three countries. Argentinian patients had a very low level of pharmacophobia. Multivariate analyses (logistic regression and chi-squared automatic interaction detector segmentation) showed that pharmacophobia in general and skepticism about specific medications (high concern about adverse reactions and low belief in their necessity) were associated with non-adherence. Pharmacophobia was the major factor associated with non-adherence (Spain and Venezuela) but when pharmacophobia was rare (Argentina), skepticism was the most important variable associated with non-adherence.

CONCLUSION

Psychiatric patients' attitudes and beliefs about their psychiatric treatment varied in these three Spanish-speaking countries, but pharmacophobia and skepticism appeared to play a consistent role in lack of adherence.

Psychotropic medication non-adherence and associated factors among adult patients with major psychiatric disorders: a protocol for a systematic review

BACKGROUND

Evidence from the global burden of diseases show that psychiatric disorders are a growing public health concern. Maintaining adherence to medication is the most essential, but challenging course in the pharmacological treatment modality for major psychiatric disorders. Nevertheless, there is a paucity of abridged evidence on the level of psychotropic medication non-adherence and associated factors. Therefore, we aim to systematically summarize existing primary studies finding to estimate the level and identify associated factors of psychotropic medication non-adherence among adult patients with major psychiatric disorders.

METHODS

We will search studies using computerized search engines, main electronic databases and other relevant sources. PubMed (Medline), EMBASE, CINAHL, PsycINFO, Web of Science, WHO Global Health Library, and direct Google search will be searched to retrieve studies written in English language before December 2017. Observational studies (cross-sectional, case-control, cohort or longitudinal, survey and surveillance reports) on major psychiatric disorders (schizophrenia, major depressive and bipolar disorders) among adult patients will be eligible. Data will be extracted independently by two authors. Data synthesis and statistical analysis will be carried out. Pooled estimate will be done to quantify the level of psychotropic medication non-adherence using Comprehensive Meta-Analysis software.

DISCUSSION

Psychiatric disorders remain a public health, social and economic concern worldwide. Management of major psychiatric disorders is highly affected by medication non-adherence. Thus, undertaking an integrated and multifaceted approach is necessary to reduce the burden of medication non-adherence, and enhance the quality of patients' life. Evidence is required to design appropriate intervention to prevent psychotropic medication non-adherence.

PROTOCOL REGISTRATION

PROSPERO: 2017: CRD42017067436 .

Why don't patients take their medicine? Reasons and solutions in psychiatry

Over the course of a year, about three-quarters of patients prescribed psychotropic medication will discontinue, often coming to the decision themselves and without informing a health professional. Costs associated with unplanned discontinuation may be substantial if left uncorrected. Partial non-adherence (much more common than full discontinuation) can also be detrimental, although some patients rationally adjust their medication regimen without ill-effect. This article reviews the literature on non-adherence, whether intentional or not, and discusses patients' reasons for failure to concord with medical advice, and predictors of and solutions to the problem of non-adherence.

Five Interpersonal Factors Are Predictive of the Response to Treatment of Major Depression With Antidepressants in Primary Care

Introduction: Factors relating to the interpersonal relationship between the patient and their physician and social environment are important components, which contribute to their response to treatment for major depressive disorder. This study aimed to assess the influence of optimism, perfectionism, therapeutic alliance, empathy, social support, and adherence to medication regimen in the response to antidepressant treatments in the context of normal primary care clinical practice. Method: We conducted a prospective study in which 24 primary care physicians administered sertraline or escitalopram to 89 patients diagnosed with major depressive disorder. The response to treatment and remission of the episode was assessed at 4 and 12 weeks by Cox regression. The effect of adherence to the medication regimen was assessed by multiple regression statistical techniques. Results: Adherence to medication (HR = 0.262, 95% CI = 0.125-0.553, p < 0.001) and patient perfectionism (HR = 0.259, 95% CI = 0.017-0.624, p < 0.01) negatively predicted the initial response to treatment, whereas patient optimism (HR = 1.221, 95% CI = 1.080-1.380, p < 0.05) positively predicted it. Patient optimism (HR = 1.247, 95% CI = 1.1-1.4, p < 0.05), empathy perceived by the patient (HR = 1.01, 95% CI = 1001-1002, p < 0.05), and therapeutic alliance (HR = 1.02, 95% CI = 1001-1.04, p < 0.05) positively predicted episode remission, while patient perfectionism (HR = 0.219, 95% CI = 0.093-0.515, p < 0.001) and low adherence to the treatment regimen (HR = 0.293, 95% CI = 0.145-0.595, p < 0.001) negatively predicted it. Finally, social support (p < 0.01) and therapeutic alliance (p < 0.05) predicted adherence to the medication regimen. Conclusions: In addition to taking the antidepressant drug, other factors including the personal interactions between the patient with their primary care physician and with their social environment significantly influenced the patients' initial response and the final rate of episode remission.

Consumer-related factors influencing antidepressant adherence in unipolar depression: a qualitative study

PURPOSE

To explore factors which facilitate and negatively impact adherence, at initiation, implementation and discontinuation phases of adherence to antidepressant medicines.

PATIENTS AND METHODS

Semi-structured, face-to-face interviews were conducted with patients suffering from unipolar depression. The digitally audio-recorded and transcribed verbatim were used. Transcripts were thematically content analyzed and data managed using N-Vivo software.

RESULTS

Twenty-three interviews were conducted. The predominant factors facilitating initiation of therapy included self-motivation and severity of depression. Factors aiding persistence with therapy included belief in, and effectiveness of, antidepressants. Stigma and fear of adverse events inhibited initiation of therapy, whilst adverse events and ineffectiveness of antidepressants contributed to discontinuation. Patients with strong perceptions of the necessity and few concerns about antidepressants were more likely to adhere to treatment at all phases of adherence.

CONCLUSION

Different factors influence medication adherence at the different phases of adherence. These factors were based on individual perceptions about depression and its treatment, and actual experiences of antidepressant treatment. This information should be considered by health care professionals in delivering targeted and tailored interventions to foster adherence. Strategies to address medication non-adherence in unipolar depression patients should consider the phase of adherence and individual perceptions about depression and its treatment, along with previous experiences with treatment for depression.

Patient-perceived barriers to a screening program for depression: a patient opinion survey of hemodialysis patients

Background

Depression is a prevalent, yet underdiagnosed, psychiatric disorder among patients with end-stage renal disease. Active case identification through routine screening is suggested; however, patient-related barriers may reduce the effectiveness of screening for, and treating, depression. This study aimed to explore the perceived barriers that limit patients from participating in screening and treatment programs for depression.

Methods

In a cross-sectional study of chronic maintenance hemodialysis patients, the Perceived Barriers to Psychological Treatment questionnaire, adapted to include screening, was used to measure perceived barriers. The two-item Patient Health Questionnaire was used to identify patients with depressive symptoms.

Results

Of 160 participants, 73.1% reported at least one barrier preventing them from participation [95% confidence interval (95% CI) 66.2–80.0%]. Patients with depressive symptoms were more likely to perceive at least one barrier to a screening program for depression compared with those without depressive symptoms (96% versus 68.9%, respectively; odds ratio = 10.8; 95% CI 1.4–82.8; P = 0.005). The association of the barrier scores with depressive symptoms remained significant after adjustment for patient’s characteristics. The most common barriers that patients expressed were concerns about the side effects of any antidepressant medications that may be prescribed (40%), concerns about having more medications (32%), feeling that the problem is not severe enough (23%) and perceiving no risk of depression (23%).

Conclusions

Negative perceptions about depression and its treatment among hemodialysis patients constitute an important barrier to identifying this condition and first need to be addressed before implementing a screening program in this population.