Development and validation of the Patient's Health Belief Questionnaire on Psychiatric Treatment

Exploring the Relationship Between Psychological Constructs and Decision-Making Preferences in Psychiatric Outpatients

Objective

This study aimed to elucidate the relationships among health locus of control, psychological reactance, attitudes toward psychiatric treatment, and patient decision-making preferences within a psychiatric outpatient population.

Methods

A total of 200 consecutive psychiatric outpatients from a community mental health center in Tenerife, Spain, were approached for participation between September 2023 and March 2024. Of these, 151 patients consented to participate in this cross-sectional study. Participants were selected based on their willingness to participate and were provided with informed consent forms. Data were collected using the Patient's Health Belief Questionnaire on Psychiatric Treatment (PHBQPT) and the Control Preferences Scale (CPS). The PHBQPT evaluates health beliefs impacting adherence to psychiatric treatment, while the CPS assesses the preferred level of involvement in medical decision-making. Sociodemographic data were also collected to contextualize the findings.

Results

Significant correlations were found between patients' control preferences and their attitudes towards medication, compliance with psychiatric advice, and perceptions of treatment control. A collaborative control preference was notably associated with positive attitudes toward medication and trust in the psychiatrist. These findings suggest that tailored treatment approaches prioritizing patient involvement could enhance adherence and outcomes.

Conclusion

 The study underscores the importance of considering psychological constructs in psychiatric care to foster a holistic, patient-centered approach. Recognizing and integrating patients' control preferences, attitudes towards medication, and psychological reactance can improve the therapeutic relationship and treatment adherence. Future research should explore longitudinal and interventional studies to further understand the impact of aligning treatment approaches with patient preferences and psychological profiles.

Psychiatric Patients' Perceived Health Control and Reactance: Implications for Medication Adherence

Adherence to prescribed treatment is a major challenge in psychiatry, with non-adherence rates estimated to be as high as 50%. Two factors that have been suggested to influence medication adherence in psychiatric patients are perceived health control and psychological reactance. Perceived health control refers to the belief that one can control their own health outcomes, while psychological reactance refers to the negative response that occurs when individuals perceive their freedom or autonomy to be threatened. The aim of this review is to explore the possible relevance and interaction of perceived health control and psychological reactance in the adherence of psychiatric patients to their treatment. Several studies have suggested that higher levels of perceived health control are associated with better medication adherence, while higher levels of psychological reactance are associated with poorer adherence. Moreover, it has been suggested that patients with high levels of perceived health control may be more likely to experience psychological reactance if they feel that their autonomy is threatened by the treatment regimen. Taken together, these findings suggest that perceived health control and psychological reactance may interact to influence medication adherence in psychiatric patients. Future research could explore ways to enhance patients' perceived health control while minimizing psychological reactance in order to improve treatment adherence in this population.

Adherence to Oral Contraception in Young Women: Beliefs, Locus of Control, and Psychological Reactance

Background: There is a high dropout rate of oral contraceptive pills (OCP), mainly due to a lack of adherence to treatment. The aim of this study was to identify the psychological processes and attitudes toward medication involved in adherence to OCP, depending on the prescription, to avoid unintended pregnancies (AUP) or gynecological problems (GP). Methods: This cross-sectional study was conducted by asking 689 young women in the fertile period, mean age 23.41 (SD = 5.90), to complete questionnaires related to attitudes, beliefs, psychological reactance, locus of control, and adherence to contraceptive medication. Descriptive analyses and a binary logistic regression were performed. Results: The results confirmed that different beliefs and psychological processes were involved in adherence to oral contraception, based on women’s reasons for taking contraceptive medication. More psychological processes were involved in non-adherence in the AUP group than in the GP group. Psychological reactance contributed most to explaining non-adherence in women who used the OCP to prevent unintended pregnancies. Conversely, women with gynecological problems reported difficulties in adherence, mainly due to their beliefs about contraceptive pills. Conclusions: These findings indicate that attitudes toward medication and psychological processes can play an important role in adherence to OCP, including reasons for using the pill. Identifying the psychological factors and beliefs linked with contraception could guide health professionals to provide counseling to women, thus increasing their adherence to medication and maximizing their health and well-being.

Effect of necessity-concern framework and polypharmacy on treatment adherence in psychiatric patients. Comparing an Argentinian with a Spanish sample

OBJECTIVE

We aimed to replicate a prior Spanish study of medication adherence where logistic regression models provided highly significant odds ratios (ORs) for three continuous scores: necessity, concern and the necessity-concern differential, and a dichotomous variable: skeptical attitude. Adherence ORs in the necessity-concern framework were very strong in patients taking five or six medications.

METHODS

The sample comprised consecutive adult psychiatric outpatients in Mendoza, Argentina. The necessity-concerns framework was assessed using a subscale of the Beliefs about Medicines Questionnaire. Adherence (yes/no) to prescribed psychiatric medications was assessed by the Sidorkiewicz adherence tool.

RESULTS

When compared with the Spanish sample, the Argentinian group (508 patients with 875 medications) was characterized by: (1) significantly stronger adherence ORs with the necessity-concern framework, (2) significantly lower number of medications per patient and percentage of patients with marked psychiatric polypharmacy (≥4 medications), (3) though a higher number of medications still was significantly associated with poor adherence.

CONCLUSIONS

The Argentinian sample replicated the previous finding that patient beliefs regarding necessity and concern were associated with poor adherence to prescribed medications. Polypharmacy had an additive role decreasing adherence in both samples. In both samples, when prescribed ≥4 psychiatric medications, patients reported adherence to only two-third of the medications.

Exploring patterns in psychiatric outpatients' preferences for involvement in decision-making: a latent class analysis approach

BACKGROUND

Shared decision-making (SDM), a collaborative approach that includes and respects patients' preferences for involvement in decision-making about their treatment, is increasingly advocated. However, in the practice of clinical psychiatry, implementing SDM seems difficult to accomplish. Although the number of studies related to psychiatric patients' preferences for involvement is increasing, studies have largely focused on understanding patients in public mental healthcare settings. Thus, investigating patient preferences for involvement in both public and private settings is of particular importance in psychiatric research. The objectives of this study were to identify different latent class typologies of patient preferences for involvement in the decision-making process, and to investigate how patient characteristics predict these typologies in mental healthcare settings.

METHODS

We conducted latent class analysis (LCA) to identify groups of psychiatric outpatients with similar preferences for involvement in decision-making to estimate the probability that each patient belonged to a certain class based on sociodemographic, clinical and health belief variables.

RESULTS

The LCA included 224 consecutive psychiatric outpatients' preferences for involvement in treatment decisions in public and private psychiatric settings. The LCA identified three distinct preference typologies, two collaborative and one passive, accounting for 78% of the variance. Class 1 (26%) included collaborative men aged 34-44 years with an average level of education who were treated by public services for a depressive disorder, had high psychological reactance, believed they controlled their disease and had a pharmacophobic attitude. Class 2 (29%) included collaborative women younger than 33 years with an average level of education, who were treated by public services for an anxiety disorder, had low psychological reactance or health control belief and had an unconcerned attitude toward medication. Class 3 (45%) included passive women older than 55 years with lower education levels who had a depressive disorder, had low psychological reactance, attributed the control of their disease to their psychiatrists and had a pharmacophilic attitude.

CONCLUSIONS

Our findings highlight how psychiatric patients vary in pattern of preferences for treatment involvement regarding demographic variables and health status, providing insight into understanding the pattern of preferences and comprising a significant advance in mental healthcare research.

Health Control Beliefs and Attitude Toward Treatment in Psychiatric and Non-Psychiatric Clinical Samples

Although there is accumulating evidence on the potential influencing factors of medication adherence, the knowledge about patients' attitudes and beliefs toward treatment is only partly utilized in adherence-improving strategies. Several internal and external factors determining adherence have been described regarding many chronic somatic diseases but in recent research, insight on psychiatric patients has been exclusively lacking. As a result, there is a scarcity of effective adherence-improving interventions. Identification of any specific differences or similarities between the attitudes toward treatment of psychiatric and non-psychiatric patients would help to support adherent behavior. We recruited 189 participants from four departments of general psychiatry (GEN PSYCH, n = 106), addictology (ADDICT, n = 42) and somatic diseases (NON PSYCH, n = 41). The Patient's Health Belief Questionnaire on Psychiatric Treatment (PHBQPT) was performed to assess the patients' attitude toward drug treatment, perceived health locus of control, and psychological reactance. The most robust difference of the PHBQT scores occurred between the GEN PSYCH and ADDICT subgroups. ADDICT patients scored significantly higher on the internal and external health locus of control and on the Psychological Reactance subscale as well. While GEN PSYCH subjects provided higher scores on the Positive Aspect of Medication compared to ADDICT persons. Interestingly, the only difference between the GEN PSYCH and NON-PSYCH groups was the more pronounced mistrust in physicians in the case of psychiatric patients. Our data suggest that mistrust toward medication does not differ in psychiatric and non-psychiatric samples, while the acceptance of the doctor's competency may be stronger in the non-psychiatric sample. The analysis of these factors provides information which could help us better understand this important issue and to develop more efficient interventions for improving adherence.

Development and Validation of the Hospital Outpatients' Information Needs Questionnaire (HOINQ)

PURPOSE

The main objective was to develop and validate a "Hospital Outpatients' Information Needs Questionnaire" (HOINQ). Secondly, to identify patients' preferred sources of information. Finally, to establish differences depending on the disease, as well as between sociodemographic and clinical variables.

PATIENTS AND METHODS

This is a transversal study based on a questionnaire. All adult hospital outpatients' who collected their medication at the Pharmacy Service were consecutively recruited, regardless of their diagnosis time, treatment or disease. The Spanish version of the internationally validated European Organization for Research and Treatment Cancer Quality of Life Questionnaire (EORTC QLQ-25) aimed at oncology patients was used as the starting point. In order to be applicable on new target population, it was crucial to make several changes and ensure that it complies with the validity, viability and reliability criteria. The questionnaire prepared for validation was then obtained by a literature review (face validity), submitting the EORTC QLQ-25 to an expert committee (content validity), by piloting (viability) and Cronbach's alpha statistical analysis (reliability). Once the questionnaire was completed, Cronbach's alpha of the final study (reliability) and factor analysis (construct validity) were performed. Then, pertinent modifications were applied to obtain the HOINQ.

RESULTS

A total of 153 outpatients filled the questionnaire, which was widely accepted and required 5-10 min to complete. Cronbach's alpha coefficients met criteria >0.7. Three factors were established by factor analysis: aspects about the disease, pharmacological and no-pharmacological treatment and satisfaction and perception of the information received. Participants felt satisfied (41-52%) with the information amount, quality and usefulness, although 1 out of 3 stated wanting to know more about the different information areas. Younger patients (P-value <0.05) and those who had been attending the Pharmacy Service for a longer time span (P-value <0.01) reported receiving more information. On a 0 to 7 scale, medical specialists (mean = 6.28, SD = 1.38) followed by the rest of health care professionals (mean = 4.23-4.63, SD = 2.25-2.29) were selected as the preferred sources of information. HIV patients reported being more informed, while those with rheumatoid arthritis felt less informed (P-value <0.05).

CONCLUSION

The HOINQ was developed. It is a self-completed questionnaire, composed of three blocks: the 16-item information needs questionnaire, demographic and clinical variables, and patients' preferred sources of information. It is an easy tool to use and replicate, both for patients and professionals.

Effects of a peer co-facilitated educational programme for parents of children with ADHD: a feasibility randomised controlled trial protocol

INTRODUCTION

Significant numbers of children with attention deficit hyperactivity disorder (ADHD) display problems that cause multiple disabilities, deficits and handicaps that interfere with social relationships, development and school achievement. They may have multiple problems, which strain family dynamics and influence the child's treatment. Parent activation, described as parents' knowledge, skills and confidence in dealing with their child's health and healthcare, has been shown to be an important factor in improving health outcomes. Research suggests that parents need edification to learn skills crucial to the treatment and management of their children's healthcare. Promoting positive parenting techniques may reduce negative parenting factors in families. This study aims to assess the acceptability, feasibility and estimated sample size of a randomised controlled trial (RCT) comparing an ADHD peer co-led educational programme added to treatment as usual (TAU).

METHODS AND ANALYSIS

Using a randomised waitlist controlled trial, parents of children aged 6-12 years newly diagnosed with ADHD, and referred to a child mental health outpatient clinic in Mid-Norway, will receive TAU concomitant with a peer co-facilitated parental engagement educational programme (n=25). Parents in the control group will receive TAU, and the educational programme treatment within a waitlist period of 3-6 months (n=25). Parent activation, satisfaction, well-being, quality of life and treatment adherence, will be assessed at baseline (T0), 2 weeks (T1) pre-post intervention (T2, T3) and at 3 months follow-up (T4). Shared decision making, parents preferred role in health-related decisions and involvement, parent-reported symptoms of ADHD and child's overall level of functioning will be assessed at T0 and T4. Such data will be used to calculate the required sample size for a full-scale RCT.

ETHICS AND DISSEMINATION

Approval was obtained from the Regional Committee for Medicine and Health Research Ethics in Mid-Norway (ref: 2018/1196). The findings of this study are expected to provide valuable knowledge about how to optimise family education and management of ADHD and will be disseminated through presentations at conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04010851.

Patient-reported well-being: psychometric properties of the world health organization well-being index in specialised community mental health settings

The Five-item World Health Organization Well-being Index (WHO-5) is an increasingly used measure of generic well-being, but there is no evidence to support whether outpatients consider the questionnaire valuable. As the WHO-5 has not yet been psychometrically evaluated in specialised community mental health settings, an evaluation of its validity seems warranted. The aim of this cross-sectional study was to examine the psychometric properties of the WHO-5 in this type of setting. Data was collected from an outpatient center (N = 191 adults). Results indicate that the questionnaire was feasible to administer (n = 57 patients), it reported low mean Burden-scores and high Positive-Value scores, and had excellent internal consistency. No evidence of floor or ceiling effects was found. Results supported the unidimensional structure of the questionnaire. Significant differences were found concerning patients' diagnoses, with patients with schizophrenia diagnoses reporting higher scores and patients with depression and personality disorders reporting lower ones. When comparing the WHO-5 total score and patients' attitudes toward medication, negative correlations were observed with psychological reactance, as well as positive aspects of psychiatric medication. The present study demonstrates that the WHO-5 is feasible to administer and has robust psychometric properties in specialised community mental health centres.

A Rational Use of Clozapine Based on Adverse Drug Reactions, Pharmacokinetics, and Clinical Pharmacopsychology

Using Richardson and Davidson's model and the sciences of pharmacokinetics and clinical pharmacopsychology, this article reviewed the: (1) poor life expectancy associated with treatment-resistant schizophrenia (TRS), which may be improved in patients who adhere to clozapine; (2) findings that clozapine is the best treatment for TRS (according to efficacy, effectiveness and well-being); and (3) potential for clozapine to cause vulnerabilities, including potentially lethal adverse drug reactions such as agranulocytosis, pneumonia, and myocarditis. Rational use requires: (1) modification of the clozapine package insert worldwide to include lower doses for Asians and to avoid the lethality associated with pneumonia, (2) the use of clozapine levels for personalizing dosing, and (3) the use of slow and personalized titration. This may make clozapine as safe as possible and contribute to increased life expectancy and well-being. In the absence of data on COVID-19 in clozapine patients, clozapine possibly impairs immunological mechanisms and may increase pneumonia risk in infected patients. Psychiatrists should call their clozapine patients and families and explain to them that if the patient develops fever or flu-like symptoms, the psychiatrist should be called and should consider halving the clozapine dose. If the patient is hospitalized with pneumonia, the treating physician needs to assess for symptoms of clozapine intoxication since halving the dose may not be enough for all patients; consider decreasing it to one-third or even stopping it. Once the signs of inflammation and fever have disappeared, the clozapine dose can be slowly increased to the prior dosage level.

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.

Chronic Conditions and Behavioural Change Approaches to Medication Adherence: Rethinking Clinical Guidance and Recommendations

Patient adherence to medication is an ongoing concern for clinicians, obfuscating treatment efficacy and resulting in wastage of medicine, reduced clinical benefit, and increased mortality. Despite this, procedural guidance on how clinicians should best engage patients regarding their medicine-taking is limited in the United Kingdom. Adherence for chronic conditions is notably complex, requiring clear education, communication, and behavioural shifts to initiate and sustain daily regimens successfully. This article explores current clinician guidance on assuring patient adherence to medication within the National Health Service, comparing it to that provided for healthcare workers in the field of behavioural change. Outlining the inertia of the former and the progress of the latter, we consider what steps should be taken to address this deficit, including greater focus on patient concerns, as well as knowledge translation for healthcare professionals in future adherence research. Current United Kingdom clinical guidance for assuring patient adherence is largely outdated based on inconclusive evidence for best practice. However, efforts to encourage behavioural change in the public health setting demonstrate evidence-based success. Integrating knowledge generated around adherence behaviour and the practical application of adherence and behavioural change research, as well as funding for longer-term studies with a focus on clinical outcomes, may help to solidify the NICE guidance on adherence and further progress the field. This would require close involvement from patient groups and networks informing ethical aspects of study design and clinical implementation.

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.