Improving adherence in mood disorders: the struggle against relapse, recurrence and suicide risk

Preliminary results from the Australian Genetics of Bipolar Disorder Study: A nation-wide cohort

OBJECTIVE

The Australian Genetics of Bipolar Disorder Study is a nation-wide cohort of adults living with bipolar disorder. The study aims to detect the relationships between genetic risk, symptom severity, and the lifetime prevalence of bipolar disorder, treatment response and medication side effects, and patterns and costs of health care usage.

METHODS

A total of 6682 participants (68.3% female; aged 44.8 ± 13.6 years [range = 18-90]) were recruited in three waves: a nation-wide media campaign, a mail-out based on prescriptions for lithium carbonate and through the Australian Genetics of Depression Study. Participants completed a self-report questionnaire. A total of 4706 (70%) participants provided a saliva sample and were genotyped and 5506 (82%) consented to record linkage of their Pharmaceutical and Medicare Benefits Schedule data.

RESULTS

Most participants were living with bipolar I disorder (n = 4068) while 1622 participants were living with bipolar II disorder and 992 with sub-threshold bipolar disorder. The mean age of bipolar disorder diagnosis was 32.7 ± 11.6 years but was younger in bipolar I (p = 2.0E-26) and females (p = 5.7E-23). Excluding depression with onset prior to bipolar disorder diagnosis, 64.5% of participants reported one or more co-occurring psychiatric disorders: most commonly generalised anxiety disorder (43.5%) and posttraumatic stress disorder (20.7%). Adverse drug reactions were common and resulted in discontinuation rates ranging from 33.4% for lithium to 63.0% for carbamazepine.

CONCLUSION

Our findings highlight the high rate of comorbidities and adverse drug reactions among adults living with bipolar disorder in the general Australian population. Future genomic analyses focus on identifying genetic variants influencing pharmacotherapy treatment response and side effects.

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

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

Low Level of Agreement Between Self-Report and Clinical Assessment of Passive Suicidal Ideation

OBJECTIVE

Discrepancies between patient reports during clinical evaluations and self-reported suicide ideation are of vital importance. We study the agreement in passive suicidal ideation between reports made by clinicians and patients' self-reports.

METHOD

Wish of death in 648 outpatients was assessed by attending clinicians. Within 24 h after clinical evaluation, patients completed a self-report questionnaire in which they were asked whether they had no desire to live. We used cluster analysis to determine the clinical profile of a population of patients according to the concordance between reports made by clinicians and self-reported information.

RESULTS

A low level of agreement (kappa = 0.072) was found between clinicians and patients, as 56.4% (n = 366) of clinician reports classified as containing no death-related ideas although on self-report the patient did state that they had no desire to live. In this group containing discrepancies between the two reports, two clusters were found to have shared characteristics: female sex, middle age, cohabitation, active employment, no history of suicidal behavior, and diagnosis of neurotic, stress-related, and somatoform disorders. In a third, more severe cluster, patients self-reported sleep disturbances, less appetite, poor treatment adherence, and aggressiveness.

CONCLUSIONS

We found low agreement between self-reports and clinician assessments regarding the death wish. Self-reporting may be useful in assessing suicide risk. HIGHLIGHTSLow agreement was found between self-reports and clinician assessments regarding passive suicidal ideation.Most patients in whom the clinician underestimated the risk of suicide were women.Our results suggest that clinicians require adequate documentation of suicidal risk assessment to identify the high-risk population.

Patients' Experiences of Engagement with Healthcare Services Following a High-Risk Self-Harm Presentation to a Hospital Emergency Department: A Mixed Methods Study

Experiences of engaging with healthcare services following a self-harm presentation to hospital of high lethality or high suicidal intent have not been examined previously, despite this subgroup of self-harm patients being at high risk of suicide. Therefore, this study addressed this issue by documenting patients' experiences of engaging with healthcare services after a high-risk self-harm (HRSH) presentation to hospital. Demographic, psychiatric and psychosocial factors associated with variations in perceptions of care received were also examined. Quantitative information was obtained by interview administered questionnaires 0-3 months following a HRSH presentation to hospital. Semi-structured follow-up interviews, conducted, 6-9 months later, provided qualitative data (n = 32). Satisfaction with aftercare varied. Positive experiences of care included "supportive and compassionate relationships" and "timely and comprehensive follow-up care." The establishment of trust in the services encouraged help-seeking and psychotropic treatment adherence. Conversely, "superficial and unsupportive relationships" and "care lacking continuity and comprehensiveness" left some participants feeling isolated, contributing to inhibited help-seeking and resistance to psychotropic treatment. Participants with a history of self-harm and mental health service engagement were more likely to report dissatisfaction with care provided. Those who described unsupportive relationships more frequently reported repeated self-harm, alcohol misuse, and hopelessness at follow-up. Our findings show that satisfaction with services, help-seeking and treatment adherence may be improved by ensuring the consistent provision of timely, comprehensive and supportive aftercare following a HRSH presentation. Absence of these aspects of care may contribute to ongoing distress and further suicidal behavior.

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.

Accuracy of self-reported adherence and therapeutic drug monitoring in a psychiatric emergency ward

The aims of the study were: (1) the evaluation of the agreement between therapeutic drug monitoring (TDM) and a self-assessment of adherence to psychopharmacological treatments; (2) the identification of predictors of TDM results.Adherence in patients admitted into a psychiatric emergency service (PES) for a relapse of a schizophrenia spectrum disorder (SSD) or a bipolar disorder (BD; DSM-5) was assessed both directly with TDM and indirectly with a self-reported measure (Medication Adherence Report Scale -MARS- 10 items). The agreement between TDM and MARS was evaluated. Fifty-seven patients with SSD and 76 people with BD participated in the study. TDM was in range in about 50% of the global sample. No evidence of an association between MARS total scores and TDM results was found. Sensitivity, specificity, positive and negative predictive values of almost all MARS total scores were near to 50%. Smoking was strongly associated with a reduction of TDM results within the reference range. In the BD group, female sex was a predictor of TDM in range. In this clinical setting, self-assessment of adherence is neither reliable nor predictive. Furthermore, smoking is a strong predictor of poor adherence to psychopharmacological therapy.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Differences in antipsychotic treatment between depressive patients with and without a suicide attempt

BACKGROUND

Depressed suicide attempters are, according to some earlier studies, treated more often with antipsychotics than depressive non-suicide attempters. Cluster B personality disorders, especially borderline personality disorder, are associated with a high suicide risk, and antipsychotics are commonly used for the reduction of symptoms. However, no previous study has taken comorbid personality disorders into account when assessing the use of antipsychotics in patients with unipolar depression. Therefore, the aim of this study was to investigate the clinical selection of pharmacotherapy in unipolar depression with and without a previous suicide attempt, taking into account potential confounders such as cluster B personality disorders.

METHODS

The study sample consisted of 247 patients with unipolar depression. The study was approved by the Regional Ethical Review Board in Lund, Sweden. Study participants were recruited from 4 different secondary psychiatric care clinics in Sweden and were diagnosed according to the DSM-IV-TR with the MINI and SCID II. Previous and ongoing psychiatric treatments were investigated in detail and medical records were assessed.

RESULTS

Thirty percent of the patients had made previous suicide attempts. Depressed suicide attempters underwent both lifetime treatment with antipsychotics and an ongoing antipsychotic treatment significantly more often than non-attempters. Significances remained after a regression analysis, adjusting for cluster B personality disorders, symptom severity, age at the onset of depression, and lifetime psychotic symptoms.

CONCLUSIONS

This is the first study to consider the effect of comorbidity with cluster B personality disorders when comparing treatment of depressive suicide and non-suicide attempters. Our findings suggest that suicide attempters are more frequently treated with antipsychotics compared to non-suicide attempters, regardless of cluster B personality disorder comorbidity. These findings are important for clinicians to consider and would also be relevant to future studies evaluating reduction of suicide risk with antipsychotics in patients with psychiatric comorbidity and a history of attempted suicide.

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.

Evaluation of long-acting injectable antipsychotics with the corresponding oral formulation in a cohort of patients with schizophrenia: a real-world study in Spain

To date, only a few studies compared some long-acting injectables (LAIs) antipsychotics showing similar symptom improvement, relapse rates and adherence to treatment. We evaluated the use of LAIs antipsychotics [aripiprazole-1-month (A1M); paliperidone-1-month and 3-month (PP1M and PP3M) and biweekly (2w)-LAIs] and their corresponding oral formulations through (1) the number of hospital re-admissions, (2) the number of documented suicidal behaviour/attempts and (3) the use of concomitant benzodiazepines, oral antipsychotics and biperiden. A total of 277 patients, ≥18 years old, were included if were treated with the corresponding oral or LAI antipsychotic during at least 12 months and were previously diagnosed with schizophrenia. Our results showed that LAIs associated significantly lower suicidal behaviour, reduced the number of hospital admissions, lower diazepam and haloperidol equivalents and mean daily dose of biperiden intake versus oral antipsychotics. Furthermore, significant differences were found between LAIs. Specifically, PP3M was associated to lower hospital admissions versus A1M; PP1M and PP3M lower doses of diazepam equivalents versus 2w-LAIs and finally, PP1M lower antipsychotic intake versus 2w-LAIs. In conclusion, LAIs improved clinical outcomes by reducing the need for concomitant treatments and hospital admissions over oral antipsychotics. PP1M and PP3M showed better outcomes versus A1M and biweekly LAIs.

Impact of Substance Use Disorder on Quality of Inpatient Mental Health Services for People With Anxiety and Depression

Objective: Substance use disorders are commonly comorbid with anxiety and depressive disorders and are associated with poor treatment outcomes. The mechanisms underlying this association remain unclear-one possibility is that patients with anxiety/depressive disorders and substance use disorders receive poorer treatment. Concerns have been raised about the quality of inpatient care received by patients with substance use disorders. The purspose of this research was to examine the quality of care received by inpatients with an anxiety or depressive disorder, comparing subgroups with or without a comorbid substance use disorder. Methods: This was a retrospective case-note review of 3,795 patients admitted to inpatient psychiatric wards in England. Data were gathered on all acute admissions with anxiety/depressive illness over a 6-month period, for a number of measures of quality of care derived from national standards. Association of coexisting substance use disorders with a variety of quality of care outcomes (relating to assessment, care planning, medication management, psychological therapies, discharge, crisis planning, and follow-up) was investigated using multivariable regression analyses. Results: In all, 543 (14.3%) patients in the study had a secondary diagnosis of a substance use disorder. Patients with substance use disorders were less likely to have had care plans that were developed jointly (i.e., with input from both patient and clinician; odds ratio [OR] = 0.76, 95% confidence interval [CI] [0.55, 0.93], p = .034) and less likely to have had their medication reviewed either during the admission (OR = 0.83, 95% CI [0.69, 0.94], p = .030) or at follow-up after discharge (OR = 0.58, 95% CI [0.39, 0.86], p = .007). Carers of patients with substance use disorders were less likely to have been provided with information about available support services (OR = 0.79, 95% CI [0.57, 0.98], p = .047). Patients with substance use disorders were less likely to have received adequate (at least 24 hours) notice in advance of their discharge (OR = 0.72, 95% CI [0.54, 0.96], p = .033), as were their carers (OR = 0.63, 95% CI [0.41, 0.85], p = .007). They were less likely to have a crisis plan in place at the point of discharge (OR = 0.85, 95% CI [0.74, 0.98], p = .044). There was also strong evidence that patients with substance use disorders were less likely to have been referred for psychological therapy (OR = 0.69, 95% CI [0.55, 0.87], p = .002). Conclusions: We found evidence of poorer quality of care for inpatients with anxiety and depressive disorders with comorbid substance use disorders, highlighting the need for more to be done to support these patients. Discrepancies in care quality may be contributed to the poor treatment outcomes experienced by patients with substance use disorders, and strategies to reduce this inequality are necessary to improve the well-being of this substantial patient group.

Association between Adherence with an Atypical Antipsychotic and with Other Psychiatric Drugs in Patients with Bipolar Disorder

BACKGROUND

Using U.S. pharmacy and medical claims, medication adherence patterns of patients with serious mental illness suggest that adherence to atypical antipsychotics may be related to adherence to other prescription drugs. This study investigated whether adherence to an atypical antipsychotic was related to adherence to other prescribed psychiatric drugs using self-reported data from patients with bipolar disorder.

METHODS

Daily self-reported medication data were available from 123 patients with a diagnosis of bipolar disorder receiving treatment as usual who took at least 1 atypical antipsychotic over a 12-week period. Patients took a mean of 4.0±1.7 psychiatric drugs including the antipsychotic. The adherence rate for the atypical antipsychotic was compared to that for other psychiatric drugs to determine if the adherence rate for the atypical antipsychotic differed from that of the other psychiatric drug by at least ±10%.

RESULTS

Of the 123 patients, 58 (47.2%) had an adherence rate for the atypical antipsychotic that differed from the adherence rate for at least 1 other psychiatric drug by at least±10%, and 65 (52.8%) patients had no difference in adherence rates. The patients with a difference took a larger total number of psychiatric drugs (p<0.001), had a larger daily pill burden (p=0.020) and a lower adherence rate with the atypical antipsychotic (p=0.007), and were more likely to take an antianxiety drug (p<0.001).

CONCLUSION

Adherence with an atypical antipsychotic was not useful for estimating adherence to other psychiatric drugs in about half of the patients with bipolar disorder.

Distant mood monitoring for depressive and bipolar disorders: a systematic review

BACKGROUND

Broadening our knowledge of the longitudinal course of mood symptoms is cardinal to providing effective long-term treatments. Research indicates that patients with mental illness are willing to engage in the use of telemonitoring and mobile technology to assess and monitor their mood states. However, without the provision of distant support, adverse outcomes and events may be difficult to prevent and manage through self-monitoring. Understanding patient perspectives is important to achieving the best balance of self-monitoring, patient empowerment, and distant supporter involvement.

METHODS

This systematic review synthesises quantitative and qualitative evidence of the effectiveness and feasibility of daily/weekly/monthly remote mood monitoring that includes distant support in participants with mood disorders. Inclusion criteria comprised mood monitoring of mood disorder patients as main intervention, study design, method of monitoring, and presence of psychotherapy and psychoeducation. Effectiveness was defined by the change in depression and/or mania scores. Feasibility was determined on participant feedback and completion/attrition rates. Studies were assessed for quality using the Mixed Methods Appraisal Tool version 2018.

RESULTS

Nine studies of acceptable quality met the inclusion criteria. Distant mood monitoring was effective in improving depression scores but not mania scores. Feasibility, as measured through compliance and completion rates and participant feedback, varied.

CONCLUSION

Distant mood monitoring with support may be a useful, acceptable, and feasible intervention for diverse groups of patients in terms of age and ethnicity. Further, it may be effective in improving symptoms of depression, increasing treatment adherence, and facilitating the prevention and management of adverse outcomes. As a task-shifting intervention, distant mood monitoring may help to alleviate the burden on mental health providers in developing countries.

Trajectories of adherence to mood stabilizers in patients with bipolar disorder

Background

Nonadherence with mood stabilizers is a major problem that negatively impacts the course of bipolar disorder. Medication adherence is a complex individual behavior, and adherence rates often change over time. This study asked if distinct classes of adherence trajectories with mood stabilizers over time could be found, and if so, which patient characteristics were associated with the classes.

Methods

This analysis was based on 12 weeks of daily self-reported data from 273 patients with bipolar 1 or II disorder using ChronoRecord computer software. All patients were taking at least one mood stabilizer. The latent class mixed model was used to detect trajectories of adherence based on 12 weekly calculated adherence datapoints per patient.

Results

Two distinct trajectory classes were found: an adherent class (210 patients; 77%) and a less adherent class (63 patients; 23%). The characteristics associated with the less adherent class were: more time not euthymic (p < 0.001) and female gender (p = 0.016). No other demographic associations were found.

Conclusion

In a sample of motivated patients who complete daily mood charting, about one quarter were in the less adherent class. Even patients who actively participate in their care, such as by daily mood charting, may be nonadherent. Demographic characteristics may not be useful in assessing individual adherence. Future research on longitudinal adherence patterns in bipolar disorder is needed.

Exploring Psychiatric Inpatients' Beliefs About the Role of Post-discharge Follow-up Care in Suicide Prevention

Introduction:

Patients are at increased risk for death by suicide following a psychiatric hospitalization. There has been limited study of the association between patient engagement in follow-up care after psychiatric hospitalization and suicide risk. Understanding why psychiatric inpatients choose to engage in post-discharge care is important in developing effective suicide prevention strategies.

Materials and Methods:

The theory of planned behavior (TPB) has been widely used to understand many health behaviors including healthcare utilization. Using the TPB, we developed an interview guide that assessed psychiatric inpatients’ attitudes and beliefs about the role of post-discharge care in addressing suicide risk. We also inquired about perception of future risk for suicide after discharge. We conducted semi-structured interviews prior to discharge and administered the Columbia-Suicide Severity Rating Scale (C-SSRS). We assessed healthcare utilization at 1 and 3 mo after discharge. We coded and grouped the transcribed data according to the three domains of the TPB model: attitudes, subjective norms, and perceived behavioral control.

Results:

Sixteen individuals consented to enrollment. More than half (N = 10) believed that they were at no or low future suicide risk after discharge. Participants who felt that their future risk for suicide was low or none were significantly older (mean 59.3 yr, SD: 8.3) and reported significantly less severe suicidal ideation in the past month (mean CSSR-S 2.5, SD 2.1) compared to those participants who believed that their future risk was high (mean age 47.5, SD: 8.6; mean CSSR-S 4.7, SD 0.5, p < 0.05). However, all participants had a lifetime history of severe suicidal ideation (mean CSSR-S > 4.7). Many participants felt that peers facilitated treatment engagement. However, participants expressed a tendency to avoid treatment if they experienced unwanted side effects, encountered stigma, or experienced poor-therapeutic alliance. Five participants experienced poor continuity of care after discharge. Of these participants, four reported at the time of discharge no or low perceived future risk of suicide and three were readmitted within 90 d after discharge.

Conclusions:

Individuals may not appreciate that they are at heightened risk for suicide after hospitalization and this may negatively impact treatment engagement.

Adherence to psychotropic medication in completed suicide in Sweden 2006-2013: a forensic-toxicological matched case-control study

OBJECTIVE

To investigate the influence of adherence to psychotropic medications upon the risk of completed suicide by comparing person-level prescriptions and postmortem toxicological findings among complete-suicide cases and non-suicide controls in Sweden 2006-2013.

METHODS

Using national registries with full coverage on dispensed prescriptions, results of medico-legal autopsies, causes of death, and diagnoses from inpatient care, estimated continuous drug use for 30 commonly prescribed psychotropic medications was compared with forensic-toxicological findings. Subjects who had died by suicide (cases) were matched (1:2) with subjects who had died of other causes (controls) for age, sex, and year of death. Odds ratios were calculated using logistic regression to estimate the risk of completed suicide conferred by partial adherence and non-adherence to pharmacotherapy. Adjustments were made for previous inpatient care and the ratio of initiated and discontinued dispensed prescriptions, a measure of the continued need of treatment preceding death.

RESULTS

In 5294 suicide cases and 9879 non-suicide controls, after adjusting for the dispensation ratio and other covariates, partial adherence and non-adherence to antipsychotics were associated with 6.7-fold and 12.4-fold risks of completed suicide, respectively, whereas corresponding risk estimates for antidepressant treatment were not statistically significant and corresponding risk increases for incomplete adherence to antidepressant treatment were lower (1.6-fold and 1.5-fold, respectively) and lacked statistical significance.

CONCLUSION

After adjustment for the need of treatment, biochemically verified incomplete adherence to antipsychotic pharmacotherapy was associated with markedly increased risks of completed suicide.

Medication nonadherence in bipolar disorder: a narrative review

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Interparental Conflict Relative to Suicidal Ideation in Chinese Adolescents: The Roles of Coping Strategies and Meaning in Life

The aim of this study was to explore the paths between interparental conflict and Chinese adolescents’ suicidal ideation. Altogether 931 adolescents (M_age = 17.84, SD = 0.77, females = 531) completed the Dyadic Consensus Scale, Self-Report Coping Scale, Meaning in Life Questionnaire, and Positive and Negative Suicide Ideation questionnaires. Mediation analyses were conducted, focusing on the relations between interparental conflict and suicidal ideation along with coping styles and a sense of meaning in life. The results showed that interparental conflict indirectly predicted adolescents’ suicidal ideation via three mediators: coping-approach strategies, presence of meaning, and the joint serial effects of coping-approach strategies and presence of meaning in Chinese adolescents. In addition, boys were more likely to be at risk for suicidal ideation than girls, so were 10th graders compared to 11th graders. These findings supported a combined distress-to-meaninglessness line of thinking along with the use of coping-approach strategies to depress self-harm ideation. Generally, interparental conflict should be kept out of youngsters’ immediate vicinity as a preventive measure of suicidal ideation.

Exploratory analysis of the French version of the beliefs about medicines questionnaire in patients with severe mental disorders: Factorial structure and reliability in specific populations of schizophrenic, bipolar and depressive patients

OBJECTIVES

The aims of our study were to explore the factor structure and psychometric properties of the French version of the Beliefs about Medicines Questionnaire (BMQ) in patients with severe mental illness and in specific populations of patients with schizophrenia, bipolar disorder and major depressive disorder.

METHODS

A cross-sectional study including patients with schizophrenia, bipolar disorder and major depressive disorder was conducted (n = 150). Principal component analysis (PCA), reliability and validity of the French version of the BMQ were performed.

RESULTS

PCA revealed a two-factor structure similar to the original structure for the BMQ-Specific scale but only a one-component solution for the BMQ-General scale in both the total sample and the three subgroups. These subscales have satisfactory internal consistency. Validity was supported by the significant correlations of all BMQ subscales with the Drug Attitude Inventory.

CONCLUSION

The French version of the BMQ appears as a three-dimensional scale and presents satisfactory psychometric properties for use in patients with severe mental illness as well as specific populations of patients with schizophrenia, bipolar disorder and major depressive disorder.

MedLink: A mobile intervention to improve medication adherence and processes of care for treatment of depression in general medicine

Background

Major depressive disorder is a common psychological problem affecting up to 20% of adults in their lifetime. The majority of people treated for depression receive antidepressant medication through their primary care physician. This commonly results in low rates of recovery. Failure points in the process of care contributing to poor outcomes include patient non-adherence to medications, failure of physicians to optimize dose and absence of communication between patients and physicians.

Objective

This pilot study evaluated the feasibility of a systemic digital intervention (MedLink) designed to address failure points and improve treatment of depression in primary care among patients during the first eight weeks of initiating a new course of antidepressant therapy.

Methods

Participants were provided with the MedLink mobile app that provided dose reminders, information and surveys of symptoms and side effects. A cellularly enabled pillbox monitored antidepressant medication adherence. Reports were provided to physicians and participants to prompt changes in medication regimen. Study outcomes were assessed via self-report and interview measures at baseline, week 4 and week 8.

Results

Medication adherence detected by the MedLink system was 82%. Participants demonstrated significant decreases in depressive symptoms on the patient health questionnaire-9 (PHQ-9) (p = 0.0005) and the Quick Inventory of Depressive Symptomatology (p = 0.0008) over the eight-week trial. Usability was generally rated favorably.

Conclusions

The MedLink system demonstrated promise as an intervention to address failure points in the primary care treatment of major depressive disorder. Current findings support the further development of MedLink through a randomized controlled trial to evaluate the efficacy of improving processes of care, patient adherence and symptoms of depression.

Predominant mania course in Indian patients with bipolar I disorder

Many long-term follow-up studies suggest that bipolar disorder (BD) is highly recurrent and that depressive episodes are commoner than hypomania/manic episodes. However, some studies from tropical countries including India suggest that the patients experience a greater proportion of manic episodes than depressive episodes. The aim of the present study was to examine the course of BD type 1 (BD I) in a sample of hospitalized Indian subjects. We examined the clinical course of 285 BD I subjects with at least 5 years of illness using standard life charting method. These subjects were hospitalized between October 2010 and October 2012. The predominant polarity (having at least two-thirds of their lifetime episodes at one polarity) was mania (79%). Unipolar mania (≥ 3 mania episodes and no episodes of depression) was observed in 48% of the subjects. The frequency of rapid cycling course was noted in 2.5% of the subjects. Predominant manic polarity group had the illness onset mostly with a manic episode (88.9%) and the predominant depressive polarity group with a depressive episode (73.8%). Mania was the predominant polarity with a high rate of unipolar mania and a majority of the subjects had greater number of manic episodes than depressive/mixed episodes. The onset polarity determined the predominant polarity during the course of illness. Predominantly, mania course could have significant implications in the treatment of bipolar disorder.

Leisure, functional disability and depression among older Chinese living in residential care homes

OBJECTIVES

Previous research has rarely examined the intervening and buffering effects of leisure on the relationship between age-related stress and health among institutionalized elders, especially in the Chinese context. This study thus examines the extent to which participation in leisure activities mediates and moderates the impact of functional disability on depression among older adults living in residential care homes in China.

METHOD

A total of 1429 participants (858 men) aged over 60 living in residential care homes, of which 46.1% experienced depression using a cut-off score ≥ 5 on the 15-item Geriatric Depression Scale, were selected from a national survey across China by using the probability proportional to size sampling method.

RESULTS

The findings showed that depression was positively predicted by functional disability and negatively predicted by participation in leisure activities. The results of the mediation analysis showed that participation in leisure activities partially mediated the relationship between functional disability and depression. Functional disability predicted depression both directly and indirectly through its negative influence on participation in leisure activities. Participation in leisure activities also significantly buffered the relationship between functional disability and depression such that the impact of functional disability was weaker for those who participated in leisure activities more frequently.

CONCLUSION

These results provide support for the mediating and moderating roles of leisure in the stress-health relationship among institutionalized elders. To enhance residents' psychological health, residential care homes are recommended to organize more leisure activities.

The effect of knowledge and expectations on adherence to and persistence with antidepressants

PURPOSE

Adherence to and persistence with antidepressants are often suboptimal. However, little is known about how patient knowledge and outcome expectations may influence antidepressant adherence and persistence.

METHOD

Individuals who had been prescribed their first antidepressant to treat depression in the preceding 6 months were recruited to an online survey via Facebook. Knowledge, education received, and initial outcome expectations were analyzed for associations with persistence and adherence.

RESULTS

Two hundred and twenty surveys were analyzed. A total of 117 participants had taken their antidepressant for at least 3 months; another 25 had never started or stopped after <3 months without consulting their doctor. Differences in expectations and various educational messages among persistent and nonpersistent participants were identified. Having received the instruction "don't stop it without checking with your doctor" was a significant independent predictor of persistence (odds ratio [OR] =5.9, 95% confidence interval [CI] =1.4-24.5). At the time of the survey, 82.7% of participants were taking an antidepressant and 77.9% were adherent. Significant independent predictors of adherence were a greater age (OR =1.1, 95% CI =1.0-1.2), knowledge (OR =1.6, 95% CI =1.1-2.3), being informed of common side effects (OR =5.5, 95% CI =1.1-29.0), and having discussed ways to solve problems (OR =3.9, 95% CI =1.1-14.5).

CONCLUSION

Improving outcome expectations and particular educational messages may increase adherence and persistence. Greater knowledge may enhance adherence. Further investigation is warranted to determine whether a focus on these simple educational messages will improve outcomes in patients who commence an antidepressant.

Pharmacogenomic medicine in autism: challenges and opportunities

Autism spectrum disorder (ASD) affects 1 in 68 children in the US and is distinguished by core deficits in social interactions. Developing pharmacologic treatments for ASD is complicated by clinical and genetic heterogeneity. Although pharmacological treatments have not been shown to be effective in treating the core symptoms of ASD (i.e., social deficits), there is evidence that the burden of emotional and behavioral problems can be reduced with pharmacotherapy. Numerous randomized clinical trials of treatments for the core ASD deficits have been conducted; however, most have provided inconclusive results due to the substantial variation in treatment response. Variation also exists in the considerable metabolic side effects of many of the current treatments. Some of this variation may be explained by differences in the underlying genetic pathways. Exploiting the link between genetic heterogeneity and clinical variation associated with behavioral problems may provide an opportunity for targeted treatment of ASD. In this review, we summarize the recent findings from pharmacogenomics studies of ASD and suggest further how understanding how genetic liability modifies the effect of drugs may present an opportunity to address the challenges of personalized medicine in autism.

MedLink: A Mobile Intervention to Address Failure Points in the Treatment of Depression in General Medicine

Major depression is common, and imposes a high burden in terms of cost, morbidity, and suffering. Most people with depression are treated in general medicine using antidepressant medication. Outcomes are poor due to failure points across the care system, including patient non-adherence, failure of physicians to optimize the treatment regimens, and lack of patient-physician communication. This study reports on the 4-week pilot deployment of MedLink, a mobile intervention aimed at systemically addressing each of these failure points. A mobile app provides the patient with information and collects data on symptoms and side-effects. A cellularly enabled pill bottle monitors medication adherence. Data from these are provided to the physician and patient to foster communication and medication adjustments. Usability evaluation was generally favorable. Medication adherence rates in this first deployment were high with no patients discontinuing, and 84% of doses taken. Depressive symptom severity was significantly reduced. This study supports the use of a comprehensive, systemic approach to mHealth solutions to enhance processes of care for depression by general medicine physicians.

Pharmacotherapy in bipolar disorders during hospitalization and at discharge predicts clinical and psychosocial functioning at follow-up

OBJECTIVE

Individuals with bipolar disorder (BD) usually report significant disability and psychosocial impairment. Both the nature and causes associated with this impairment are poorly understood. In particular, research examining the impact of pharmacotherapy on the different aspects of psychosocial functioning in bipolar patients is currently lacking. The aim of this study was to assess to what extent the psychotropic medications used during psychiatric hospitalization and at discharge can predict clinical psychosocial functioning and the severity of the illness at follow-up in inpatients with bipolar disorder (BD).

METHODS

Patients were 71 adult BD patients contacted on average 31 months after discharge who completed at the follow-up a telephone interview based on the Health of the Nation Outcome Scales (HoNOS).

RESULTS

All the subjects completed the follow-up assessment between 5 and 75 months after discharge. The mean raw score for the HoNOS-6 was 5.70 ± 5.37. Patients with more severe behavior problems more often had been prescribed atypical antipsychotics and anticonvulsants at discharge. Patients with more severe psychosocial functioning problems more often had a history of suicide attempts, and were more often prescribed anxiolytics during hospitalization and less often prescribed lithium at discharge.

CONCLUSIONS

Having been prescribed anxiolytics and atypical antipsychotics during hospitalization predicted reduced psychosocial functioning, whereas prescription of lithium at discharge was associated with better psychosocial functioning at follow-up. Future studies are needed in order to investigate how psychosocial functioning may be related in the long-term to pharmacological treatment in patients after discharge.

Agomelatine but not melatonin improves fatigue perception: a longitudinal proof-of-concept study

Chronic Fatigue Syndrome (CFS) represents a disabling condition characterized by persistent mental and physical fatigue, bodily discomfort and cognitive difficulties. To date the neural bases of CFS are poorly understood; however, mono-aminergic abnormalities, sleep-wake cycle changes and prefrontal dysfunctions are all thought to play a role in the development and maintenance of this condition. Here we explored in a group of 62 CFS subjects the impact on fatigue levels of agomelatine, an antidepressant with agonist activity at melatonin receptors (MT1 and MT2) and antagonist activity at serotoninergic 2C receptors (5HT2C). To tease out the relative effects of MT-agonism and 5HT2C antagonism on fatigue, we compared agomelatine 50mg u.i.d. with sustained release melatonin 10mg u.i.d. in the first 12-week-long phase of the study, and then switched all melatonin-treated subjects to agomelatine in the second 12-week-long phase of the study. Agomelatine treatment, but not melatonin, was associated with a significant reduction of perceived fatigue and an increase in perceived quality of life. Moreover the switch from melatonin to agomelatine was associated with a reduction of fatigue levels. Agomelatine was well tolerated by all enrolled subjects. Our data, albeit preliminary, suggest that agomelatine treatment could represent a novel useful approach to the clinical care of subjects with CFS.

Comorbidity of personality disorders in mood disorders: a meta-analytic review of 122 studies from 1988 to 2010

BACKGROUND

A meta-analysis was conducted to identify the proportions of comorbid personality disorders (PD) in mood disorders.

METHODS

We found 122 empirical papers published in the period 1980-2010 on participants having mood disorders in addition to a comorbid PD. Mood disorders were classified as bipolar disorders (BD), major depressive disorders (MDD) and dysthymic disorders (DYS). Several moderators were coded as well.

RESULTS

The risk of having at least one comorbid PD (any PD) was high across all three mood disorders (BD=.42, MDD=.45), but highest in DYS (.60). Cluster B and C PDs were most frequent in BD, while cluster C PDs dominated in MDD and DYS. Among the specific PDs, the paranoid (.11 versus .07/.05), borderline (.16 versus .14/.13), histrionic (.10 versus .06/.06) and obsessive-compulsive (.18 versus .09/.12) PDs occurred more frequently in BD versus MDD/DYS, whereas the avoidant PD (.22 versus .12/.16) was most frequent in DYS versus BD/MDD. Moderator analyses showed higher comorbidity when diagnoses were based on questionnaires versus clinical interviews, DSM-III-R versus DSM-IV, more women were included or the duration of the disorder was longer. Age of onset yielded mixed results.

LIMITATIONS

Blind rating of diagnoses was recorded, but was employed in too few studies to be usable as an indication of diagnostic validity.

CONCLUSIONS

Personality disorders are common in mood disorders. Implications of the identified moderators as well as the new DSM-5 diagnostic system are considered.

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

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

Determinants of uptake of whole-body skin self-examination in older men

Early detection through whole-body Skin Self-Examination (wbSSE) may decrease mortality from melanoma. Using the Health Action Process Approach (HAPA) or Health Belief Model (HBM) we aimed to assess determinants of uptake of wbSSE in 410 men 50 years of older who participated in the control group of a randomized trial. Overall, the HAPA was a significantly better predictor of wbSSE compared to the HBM (p < .001). The construct of self-efficacy in the HBM was a significant predictor of future wbSSE (p = .001), while neither perceived threat (p = .584) nor outcome expectations (p = .220) were. In contrast, self-efficacy, perceived threat, and outcome expectations predicted intention to perform SSE, which predicted behavior (p = .015). The HAPA construct volitional self-efficacy was also associated with wbSSE (p = .046). The use of the HAPA model for future SSE interventions for this population is warranted.

Depression Treatment Non-adherence and its Psychosocial Predictors: Differences between Young and Older Adults?

Depression is a common disease among young and older adults. Although it can be treated, non-adherence is very common among individuals of different ages. The aim of the present paper is to review and summarize research findings regarding depression among young and older adults, with a special focus on the phenomenon of treatment non-adherence among young and older adults with depression. The first section of the review focuses on describing the characteristics of depression in young and older adults. The second section focuses on treatment non-adherence of young and older adults, the prevalence of this phenomenon, and its consequences. The third section focuses on several factors (illness beliefs, treatment beliefs, self-stigma, and self-esteem) that were identified as having a significant association with treatment non-adherence of individuals with depression, with special attention focused on age differences. Results of the review of the literature reveal that research in the area of depression treatment non-adherence and its predictors among young and older adults has received, to date, very minor and limited attention. Thus, there is a need to expand the current body of knowledge and promote future interventions geared towards the unique characteristics of depression among young and older adults, in order to increase their treatment adherence.

Agomelatine, a novel intriguing antidepressant option enhancing neuroplasticity: a critical review

OBJECTIVES

The treatment of major affective disorders, commonly associated with high disability and elevated social costs may be still considered unsatisfactory. Among all antidepressant drugs, predominantly acting through monoaminergic mechanisms, agomelatine is of particular interest due to another alternative mechanism of action. Targeting melatonergic receptors, agomelatine play a crucial role in synchronizing circadian rhythms, known to be altered in depressed subjects.

METHODS

A critical review of the literature focusing on efficacy, safety and tolerability of agomelatine in major affective disorders was performed. Additionally, we focused on the potential of agomelatine in enhancing neuroplasticity mechanisms and promote neurogenesis. A total of 136 articles from peer-reviewed journals were identified, of which 50 were assessed for eligibility and 21 were included.

RESULTS

Agomelatine, a melatonergic analogue drug acting as MT1/MT2 agonist and 5-HT2C antagonist, has been reported to be effective as antidepressant drug. Studies confirmed not only clinical efficacy but also safety and tolerability of agomelatine. Also, it enhances neuroplasticity mechanisms and adult neurogenesis in brain areas such as hippocampus and prefrontal cortex.

CONCLUSIONS

Agomelatine actually represents an intriguing option in the treatment of affective disorders.

A study on the mutual causation of suicide reporting and suicide incidences

BACKGROUND

Little research has been done on the complex relationships between the effect of news reporting on suicide incidence and vice versa (i.e., mutual causation). Furthermore, few studies have examined whether the entry of a new media outlet into a market changes the media dynamics in that market.

METHODS

A recursive two-way feedback model was used to test for mutual causation between suicide reporting and suicide incidence on a daily basis. We applied the model to examine the effect of the arrival of the Apple Daily (AD) newspaper in Taiwan and whether its suicide reporting affected the suicide incidence and suicide reporting of two other newspapers, the United Daily (UD) and the China Times (CT).

RESULTS

The AD's entry into Taiwan led to a major shift in the relationship between suicide incidence and suicide reporting. The AD stimulated more suicide coverage by the UD and the CT the following day; conversely, the UD and the CT had no such impact on the AD. Before the entry of the AD, there was little correlation between daily suicide incidence and suicide reporting, but the suicide reporting of the UD and CT correlated significantly with daily suicide incidence after the entry of the AD.

LIMITATIONS

Media impact was assessed by number of news items; detailed content analysis of the reporting was not conducted.

CONCLUSIONS

The vicious business competition facing new dailies in Taiwan's media market has changed the mass media ecology. Efforts to prevent suicide by regulating the media should closely monitor not only the behavior of newcomers, but also the established news media's reaction to new competitors.

Depression and affective temperaments are associated with poor health-related quality of life in patients with HIV infection

INTRODUCTION

Human immunodeficiency virus (HIV) represents one of the most chronic and debilitating infections worldwide. Hopelessness and affective temperaments (mood that is characteristic of an individual's habitual functioning) may play important roles in the health-related quality of life (HRQoL) of patients with HIV. The purpose of this study was to examine affective temperaments in a sample of patients with HIV, the impact of hopelessness on HRQoL, and associations among HRQoL, hopelessness, and affective temperaments.

METHODS

The study involved 88 participants who were administered the short- form health survey (SF-36), the Beck hopelessness scale (BHS), the suicidal history self-rating screening scale (SHSS), the Gotland male depression scale (GMDS), and the temperament evaluation of Memphis, Pisa, Paris and San Diego (TEMPS-A).

RESULTS

Patients with a poorer HRQoL reported more severe depression and hopelessness than patients with a higher HRQoL. Patients with a poorer HRQoL also had higher scores on all dimensions of the TEMPS-A with a depressive component compared to patients with a higher HRQoL. The small sample size in this study limits the generalizability of the findings.

CONCLUSION

Patients with a poorer HRQoL were more depressed and also at an increased risk of suicide as indicated by the more severe hopelessness they reported compared to patients with higher HRQoL. These patients were also more likely to have depressive affective temperaments than those with a higher HRQoL.

Do stroke patients have an increased risk of developing suicidal ideation or dying by suicide? An overview of the current literature

Stroke is a leading cause of death that affects 15 million people worldwide each year. Increasing evidence suggests that stroke confers substantial risk for suicide and following a stroke, patients frequently develop poststroke depression, which is a well-established risk factor for suicide. In this overview of the current literature, we examined the association between suffering a stroke and subsequent risk for suicide and suicidal ideation. We performed a careful MedLine, Excerpta Medica, PsycLit, PsycInfo, and Index Medicus search to identify all articles and book chapters in English. We initially selected 31 articles published between 1990 and 2011; however, only 16 studies were included in this review. All articles identified stroke as a significant risk factor for suicide, especially among depressed patients, providing further support for poststroke depression and suicidality. The results also indicated that there were differences between patients who developed acute-onset suicidal plans and those who reported delayed-onset plans, which occurred more frequently. Many of the stroke patients who died by suicide suffered from depression prior to their death, suggesting that being diagnosed with a mood disorder contributes to an increased risk of suicide in this population. Suffering from a stroke increases the risk of dying by suicide and developing suicidal ideation, particularly in young adults and women. The factors found to confer the most risk for suicidality were depression, previous mood disorder, prior history of stroke, and cognitive impairment.

Depression as a predictor of falls amongst institutionalized elders

OBJECTIVE

In this study, we set out to examine the combined effects of medical condition and depression status on fall incidents amongst institutionalized elderly people.

METHODS

A cross-sectional study was carried out to investigate the fall history of institutionalized elders involving 286 subjects. Experiences of falls over the previous year were recorded, with at least two falls during the prior one-year period, or one injurious fall defined as 'fallers'. The Geriatric Depression Scale-15 was used as a screening instrument for depression status.

RESULTS

Based on a multivariate logistic regression and stratification analysis, depression was found to have enhanced effects with various medical conditions on fall risk. As compared with the non-depressive reference group, a five-fold fall risk was discernible amongst depressed elders with multiple medications, whilst a six-fold risk was found amongst depressive elders using ancillary devices, along with a 11-fold amongst depressive elders with neural system diseases.

CONCLUSIONS

This study provides the evidence of enhancing effects between depression and medical conditions on the risk of falls amongst institutionalized elderly people. Thus, depressed elders with neural system diseases, using ancillary devices or multiple medications, should be specifically listed as very high risk of falling amongst institutionalized elderly, and strictly prevent them from falls. Screening and treatment of depression could also be a useful strategy in the prevention of falls amongst institutionalized elderly with poor medical condition.

[Bipolar affective disorder: pharmacotherapeutic profile and adherence to medication]

This cross-sectional and descriptive study aimed to verify the adherence of patients with Bipolar Affective Disorder (BAD) to medication and to identify possible causes of adherence and non-adherence to medication according to the pharmacotherapeutic profile. The study was carried out in a mental health service in a city in the interior of the state of São Paulo. Participants included 101 patients with BAD. Structured interviews and the Morisky-Green test were used for data collection, and the Statistical Package for Social Science was employed for data analysis. Most subjects (63%) did not adhere to medication. Although there were no significant differences between the adherent and non-adherent groups for the researched variables, the use of polypharmacotherapy and complex treatment regimens was observed in treatment for BAD. In practice, implementing strategies to improve the adherence of patients to medication treatment remains a challenge.

A systematic review of the psychosocial difficulties relevant to patients with migraine

Migraine is a common disease which causes significant burden to individuals, in terms of personal suffering and activity reduction, and to societies, in terms of disease cost. The purpose of this study is to identify the most relevant psychosocial difficulties related to migraine, the variables associated with them and the most relevant determinants of their evolution over time. MEDLINE and PsychINFO were searched for studies published in English between 2000 and 2010 that examined psychosocial difficulties in persons with migraine with and without aura, from clinical trials and observational studies. Information on the description of each difficulty, its determinants of onset and change over time and associated variables were extracted and categorized at a higher level. In total, 34 difficulties have been collected from 51 papers: the most frequent were reduced vitality and fatigue, emotional problems, pain, difficulties at work, general physical and mental health, social functioning and global disability. Evidence exists that pharmacological treatments have an impact toward improvement in patients’ difficulties, in particular emotional problems, physical and mental health, difficulties with employment and global disability. Migraine treatments and decreased headaches frequency are the major determinants of improvements in psychosocial difficulties, while no information is available for determinants of worsening; understanding the role of such factors is of primary public health relevance, given the high prevalence and the relevant personal and societal costs of migraine.

How does subjective experience of pain relate to psychopathology among psychiatric patients?

OBJECTIVE

The study aimed to investigate to what extent general psychopathology is associated with subjective experience of pain in psychiatric outpatients without comorbidity with severe physical diagnosis and whether there are any differences in the experience of pain between genders or diagnoses.

METHOD

Participants were 575 consecutive outpatients affected by mood disorder or anxiety disorder. Patients completed the West Haven-Yale Multidimensional Pain Inventory (WHYMPI) and the Symptom Checklist 90-Revised.

RESULTS

Women had higher mean scores on the Global Severity Index (1.52±0.76 vs. 1.33±0.79), higher perception of negative responses from others (1.84±1.59 vs. 1.46±1.35) and higher perception of pain severity (3.31±1.73 vs. 2.88±1.63) than men. They also reported higher mean scores on the WHYMPI's General Activity (2.14±0.98 vs. 1.93±0.95) and Household Chores (3.64±1.75 vs. 2.27±1.58) and lower mean scores on the Outdoor Work (1.24±1.26 vs. 1.87±1.51) dimension than men. Higher pain severity, more negative responses from others and higher household chores are predictors of higher psychopathology, while the general level of activity may be considered as a protective factor.

CONCLUSIONS

Pain and its subjective experience play a central role in psychiatric disorders, and it is a great burden for patients and caregivers. Clinicians should pay more attention to recognize and adequately treat painful symptoms in patients with anxiety and depressive disorder.

Medication therapy: adherence, knowledge and difficulties of elderly people from bipolar disorder

This study aimed to verify the adherence, knowledge and the difficulties of elderly patients with Bipolar Affective Disorder (BAD) in relation to the prescribed pharmacological therapy for the control of this disorder. The study included 17 elderly patients with BAD treated at a Mental Health Center. Semi-structured interviews were conducted and scales were applied. The data were analyzed using a quali-quantitative approach. A low level of adherence to the pharmacological treatment and a deficit in knowledge in relation to the medication were identified, especially regarding the dose and frequency of administration. Among the difficulties inherent to the pharmacotherapy, the obligation of polypharmacotherapy, the desire to quit the pharmacological treatment, limitations in the self-administration of the medication, collateral effects, and doubts about the need for the medication were related. Investment is needed in educational activities and in the promotion of adherence that address the difficulties experienced by elderly people with BAD in the following of the pharmacotherapy in order to ensure safety in the medication therapy.

Assessment of depressive symptoms and functional outcomes in patients with major depressive disorder treated with duloxetine versus placebo: primary outcomes from two trials conducted under the same protocol

OBJECTIVE

Return of functional ability is a central goal in the treatment of major depressive disorder. We conducted two trials with the same protocol that was designed to assess functioning after 8 Weeks of treatment with duloxetine.

METHODS

The a priori primary outcome was improvement in the Hamilton Depression Rating Scale (HAMD) item 7 (work/activities). Secondary outcomes included improvement in depressive symptoms assessed by the HAMD Maier subscale, and improvement in functioning assessed by the Sheehan Disability Scale (SDS), and the Social Adaptation Self-evaluation Scale (SASS). Patients were randomly assigned to duloxetine 60 mg/day (Trial I, n = 257; Trial II, n = 261) or placebo (Trial I, n = 127; Trial II, n = 131). Changes from baseline were analyzed using a mixed-effects model repeated measures approach.

RESULTS

At Week 8, duloxetine was superior to placebo in improving HAMD work/activities (p < 0.001) in Trial II, but not Trial I (p = 0.051), and Maier scores (p < 0.01) in both trials. At Week 12, duloxetine was superior to placebo on improving SASS scores in both trials, and the SDS in Trial II.

CONCLUSION

Treatment with duloxetine was associated with significant improvement in depressive symptoms compared with placebo, but improvement in HAMD work/activities was inconsistent at 8 weeks.

No association between hormonal abnormality and sexual dysfunction in Japanese schizophrenia patients treated with antipsychotics

OBJECTIVE

Although sexual dysfunction is believed to be caused by hormonal abnormalities, few reports have studied sexual dysfunction and its association with hormonal abnormalities in Asian populations with schizophrenia.

METHODS

We employed a cross-sectional, case-control survey design to collect data from 191 (108 men) Japanese schizophrenia outpatients treated with antipsychotics and 182 (49 men) healthy subjects. Sexual dysfunction was evaluated using the Udvalg for Kliniske Undersøgelser (UKU) Side Effect Rating Scale. We measured plasma concentrations of prolactin in both genders and testosterone in men and estradiol in women.

RESULTS

Multiple regression analyses revealed the following findings: the number of antipsychotics correlated with diminished sexual desire (standardized beta = 0.241, p < 0.05); the dose of antipsychotics correlated with gynecomastia (standardized beta = 0.277, p < 0.01), increased sexual desire (standardized beta = 0.229, p < 0.05), and ejaculatory dysfunction (standardized beta = 0.248, p < 0.05); and the dose of antipsychotics correlated with menorrhagia in women (standardized beta = 0.284, p < 0.05). However, neither plasma concentrations of prolactin, testosterone nor estradiol correlated with sexual dysfunction.

CONCLUSIONS

The present study demonstrated that an association between sex hormone abnormalities and sexual dysfunction is unlikely but that the dose or number of antipsychotics is associated with some sexual dysfunction.

Approach to antihypertensive adherence: a feasibility study on the use of student health coaches for uninsured hypertensive adults

Despite pharmacologic advances, medication non-adherence continues to challenge primary care providers in blood pressure (BP) management. Medical, nursing and pharmacy students (n=11) were recruited and trained as health coaches for uninsured, hypertensive patients (n=25) of a free clinic in an uncontrolled open trial. Pre-post analysis was conducted on BP, medication adherence, frequency of home BP monitoring, and health behavior (eg, diet, exercise). Patient satisfaction and feasibility of a student coach model was qualitatively evaluated. In the 12 patients who completed the intervention, an increase in medication adherence as measured by the Brief Medication Questionnaire was observed (P<.01), with a 11 mmHg reduction in systolic BP (P=.03). Qualitative data showed patient satisfaction with the intervention and other health behavior change. This feasibility study shows use of student health coaches to combat medication non-adherence in uninsured, hypertensive adults is promising.