Updated strategies for the management of poor medication adherence in patients with bipolar disorder

INTRODUCTION

Suboptimal adherence is a well-established, pervasive problem in individuals with bipolar disorder (BD) causing disability, suffering, and cost.

AREAS COVERED

This review covers new research since January 2016 regarding internal (patient-centered) and external (system level) barriers and facilitators to adherence. Measures of adherence, the efficacy of psychosocial adherence enhancement interventions in individuals with BD, and, finally, novel delivery systems for BD medication are also covered. Measures of adherence continue to fall broadly into objective measures (i.e. drug levels) and more subjective, self-report measures and a combination of these likely provides the most comprehensive picture. Efficacious components of psychosocial adherence enhancement interventions include psychoeducation, motivational interviewing, and cognitive behavioral strategies, yet methods for delivery vary. Long-acting injectable (LAI) medications for BD are the drug delivery system with the most promise for BD. Combining psychosocial components with novel drug delivery systems has the potential for establishing and maintaining medication adherence.

EXPERT OPINION

Psychosocial interventions improve adherence in individuals with BD. Psychoeducation is a necessary but not sufficient component in psychosocial interventions. LAIs should be considered earlier for adherence improvement than many treatment guidelines currently suggest. Comparative studies are lacking as is research into novel systems of medication delivery.

A customized adherence enhancement program for adolescents and young adults with suboptimal adherence and bipolar disorder: Trial design and methodological report

BACKGROUND

The onset of bipolar disorder (BD) is common during late adolescence and young adulthood (AYA). Suboptimal medication adherence is a critical yet modifiable risk factor for negative outcomes among AYAs with BD.

METHODS

This research used an iterative process (e.g., focus groups, advisory board, cognitive interviews) to modify an existing adherence intervention to address suboptimal adherence in AYAs with BD. The modified version of Customized Adherence Enhancement for Adolescents and Young Adults (CAE-AYA) will be compared to an Enhanced Treatment as Usual condition (ETAU) in 40 AYAs intervention using a 6-month prospective, randomized controlled trial (RCT) in a high-risk group of 16-21 year old AYAs with BD with demonstrated non-adherence to their prescribed BD medications.

CONCLUSIONS

This report describes the methodology and design of the ImprovinG adhereNce In adolescenTs with bipolar disordEr (IGNITE) study. If successful, the CAE-AYA approach has the potential to advance care for vulnerable youth with BD.

A Real-World Study of the Association between a Brief Group Psychoeducation and the Course of Bipolar Disorder

Although pharmacotherapy is considered the first-line treatment for bipolar disorders (BD), adjunctive psychoeducation has proven its effectiveness in improving self-management of the disease and reducing relapse rates. Few studies have evaluated the effect of brief group psychoeducation on pragmatic variables, such as the number of hospitalizations. The aim of the present study was to assess the mid-term effect of a four-session group psychoeducation on course-related variables in BD. Thirty-two individuals with BD were included in the study. Sixteen were exposed to psychoeducation and were matched to sixteen nonexposed individuals who received their usual treatment. Both groups were compared on insight, treatment adherence, change in the number of hospitalizations and visits to the emergency services, occurrence rate after intervention, and time to the first psychiatric hospitalization and the first urgent attendance. There was a significant reduction in the mean number of hospitalizations and urgent attendances in the exposed group in comparison to the nonexposed group. The first urgent attendance was significantly sooner in the nonexposed cohort. There were no differences between groups in any of the other variables. This intervention has shown benefits for pragmatic variables of the disease course and may be a feasible and cost-effective intervention to routinely implement in the management of BD.

The Role of Learning Support and Chat-Sessions in Guided Internet-Based Cognitive Behavioral Therapy for Adolescents With Anxiety: A Factorial Design Study

BACKGROUND

Increased awareness of anxiety in adolescents emphasises the need for effective interventions. Internet-based cognitive behavioural therapy (ICBT) could be a resource-effective and evidence-based treatment option, but little is known about how to optimize ICBT or which factors boost outcomes. Recently, the role of knowledge in psychotherapy has received increased focus. Further, chat-sessions are of interest when trying to optimize ICBT for youths. This study aimed to evaluate the role of learning support and chat-sessions during ICBT for adolescent anxiety, using a factorial design.

METHOD

A total of 120 adolescents were randomised to one of four treatment groups, in a 2x2 design with two factors: with or without learning support and/or chat-sessions.

RESULTS

Anxiety and depressive symptoms were reduced (Beck Anxiety Inventory- BAI; Cohen's d =0.72; Beck Depression Inventory- BDI; d =0.97). There was a main effect of learning support on BAI (d =0.38), and learning support increased knowledge gain (d =0.42). There were no main effects or interactions related to the chat-sessions. Treatment effects were maintained at 6-months, but the added effect of learning support had by then vanished.

CONCLUSION

ICBT can be an effective alternative when treating adolescents with anxiety. Learning support could be of importance to enhance short-term treatment effects, and should be investigated further.

Medication Adherence Using Electronic Monitoring in Severe Psychiatric Illness: 4 and 24 Weeks after Discharge

Objective

The purpose of this study was to examine post-hospitalization outpatient drug adherence in patients with severe psychiatric illness, including bipolar disorder and schizophrenia, and to investigate factors associated with drug adherence.

Methods

Eighty-one patients diagnosed with schizophrenia or bipolar disorder who were hospitalized due to aggravation of psychiatric symptoms were monitored. At hospitalization, we conducted clinical assessments such as the Clinical Global Impression-Severity, Drug Attitude Inventory, Contour Drawing Rating Scale, Multidimensional Scale of Perceived Social Support scale, and patients’ demographic factors. We measured drug adherence using the Medication Event Monitoring System (MEMS), pill count, and patients’ self-report upon out-patients visits, 4 and 24 weeks after discharge.

Results

The mean values of the various measures of adherence were as follows: MEMS (4 weeks) 84.8%, pill count (4 weeks) 94.6%, self-report (4 weeks) 92.6%, MEMS (24 weeks) 81.6%, pill count (24 weeks) 90.6%, and self-report (24 weeks) 93.6%. The adherence agreement between MEMS, pill count, and self-report was moderate (4 weeks intra-class correlation [ICC]=0.54, 24 weeks ICC=0.52). Non-adherence (MEMS ≤0.08) was observed in 26.4% of the patients at 4 weeks and 37.7% at 24 weeks. There was a negative correlation between drug adherence assessed 4 weeks after discharge and Contour Drawing Rating Scale difference score (r=−0.282, p<0.05). A positive correlation was found between drug adherence assessed 24 weeks after discharge and Drug Attitude Inventory (r=0.383, p<0.01).

Conclusion

Patients’ attitude towards their medication and their degree of physical dissatisfaction influenced post-hospitalization drug adherence in severe psychiatric patients.

The role of knowledge in internet-based cognitive behavioural therapy for adolescent depression: Results from a randomised controlled study

BACKGROUND AND OBJECTIVES

Clients' knowledge about their condition and treatment is considered crucial for general health improvement, and knowledge acquisition is an essential part in internet-based cognitive behavioural therapy (ICBT). Yet, little is known about the role of knowledge and how it influences treatment outcome. This study aimed to examine if explicit knowledge increased following ICBT for adolescent depression, if knowledge gain would be associated with symptom reduction, and if pre-existing knowledge predicted changes in depressive symptoms.

METHODS

Seventy-one adolescents were randomised to a therapist-supported ICBT or a attention control condition. A measure of depression (BDI-II) and a knowledge test dealing with depression, comorbid anxiety, and its CBT-treatment were administered before and after treatment.

RESULTS

Significant improvements in knowledge were observed following ICBT compared to the attention control (between-group Cohen's d = 1.25, 95% CI [0.67-1.79]). On average, participants in the treatment group answered 1.4 more questions correctly at post treatment compared to the control group. No relation between change in knowledge and change in depressive symptoms could be observed. Knowledge scores at baseline were high for both groups, with participants answering approximately 75% of the questions correct. A higher level of initial knowledge level predicted poorer treatment response (Parson's r = -0.38, p = .048).

CONCLUSIONS

The findings indicate that knowledge about basic concepts and principles about depression, anxiety, and CBT increases following ICBT. This increase in knowledge was not related to change in depressive symptoms, indicating that knowledge is a different construct. The results also suggest that clients who are more knowledgeable prior to treatment might benefit less from ICBT. In sum, the results highlight the need to further examine the role of knowledge in ICBT.

The Effect of Group Psychoeducation Program on Medication Adherence in Patients with Bipolar Mood Disorders: a Randomized Controlled Trial

Introduction: Medication nonadherence is highly prevalent in patients with bipolar disorders and often results in worsening disease prognosis. The purpose of this study was to investigate the effect of group psychoeducation on medication adherence in female patients with bipolar mood disorder type I.

Methods: This randomized controlled trial was conducted on 76 patients with bipolar mood disorder admitted in female psychiatric wards of Razi teaching hospital, Tabriz, Iran. The participants were selected by convenience sampling method and were randomly assigned to experimental and control groups. Patients in experimental group received 10 continuous 90 minutes sessions of psychoeducation, two times a week. Medication adherence was measured using the medicine check list and medication adherence rating scale (MARS) before and after intervention. Data analysis was performed with SPSS ver.13.

Results: There was no significant difference between two groups regarding medication adherence before the intervention. After the study intervention, the mean scores of medication adherence check list and medication adherence rating scale in the experimental group were significantly higher than the control group.

Conclusion: Since group psychoeducation was effective in improving patients' medication adherence, it could be recommended for psychiatric nurses to apply this intervention in the clinical setting.

Medication Adherence in Patients with Bipolar Disorder: A Comprehensive Review

Poor medication adherence is a pervasive problem that causes disability and suffering as well as extensive financial costs among individuals with bipolar disorder (BD). Barriers to adherence are numerous and cross multiple levels, including factors related to bipolar pathology and those unique to an individual's circumstances. External factors, including treatment setting, healthcare system, and broader health policies, can also affect medication adherence in people with BD. Fortunately, advances in research have suggested avenues for improving adherence. A comprehensive review of adherence-enhancement interventions for the years 2005-2015 is included. Specific bipolar adherence-enhancement approaches that target knowledge gaps, cognitive patterns, specific barriers, and motivation may be helpful, as may approaches that capitalize on technology or novel drug-delivery systems. However, much work remains to optimally facilitate long-term medication adherence in people with BD. For adherence-enhancement approaches to be widely adapted, they need to be easily accessible, affordable, and practical.

Healthcare use and costs associated with children's behavior problems

The objective of the study was to investigate associations between severity of behavior problems, specific symptom domains with healthcare use and costs in school-aged children. A cross-sectional study using data from the 10-year follow-up of two population-based birth cohorts was conducted on four rural and urban communities in Germany. There were 3,579 participants [1,834 boys (51%), 1,745 girls (49%)] on average aged 10.4 years. The severity levels (normal, at risk, abnormal) and symptom domains of behavioral problems were assessed by parent-reported strengths and difficulties questionnaire (SDQ).The outcomes were medical use categories (physicians, therapists, hospital, and rehabilitation), medical costs categories and total direct medical use and costs (calculated from parent-reported utilization of healthcare services during the last 12 months). Total direct medical costs showed a graded relationship with severity level (adjusted p < 0.0001). Average annual cost difference in total direct medical costs between at risk and normal total difficulties was Euro (<euro>) 271 (SD 858), and <euro> 1,237 (SD 2,528) between abnormal and normal total difficulties. A significant increase in physician costs showed between children with normal and at risk total difficulties (1.30), and between normal and abnormal total difficulties (1.29; p < 0.0001). Between specific symptom domains, children with emotional symptoms showed highest costs for physicians, psychotherapist, and hospitalization as well as total direct medical costs. Children with hyperactivity/inattention showed highest costs for therapists and emergency room costs. Healthcare use and costs are related to the severity of child behavior problems. In general, children's costs for psychotherapy treatments have been low relative to general medical treatments which may indicate that some children with behavioral problems did not get appropriate care. To some degree, medical conditions may be attributable to some of the high hospitalization costs found in children with emotional symptom.

Factors affecting treatment compliance in patients with bipolar I disorder during prophylaxis: a study from Turkey

OBJECTIVES

Treatment noncompliance is one of the most frequent causes of relapse and recurrence in patients with bipolar I disorder. Treatment compliance among patients with bipolar disorder is affected by individual patients' features, the disease itself, doctor-patient relationships and patients' socio-economic and cultural characteristics. This study aimed to determine the factors affecting treatment compliance during the treatment of bipolar disorder and contribute to current clinical strategies.

METHODS

Data were collected from 78 volunteers with bipolar I disorder in remission; all volunteers were being treated solely with mood stabilisers. Sociodemographic and clinical data were gathered through a semi-structured interview designed by researchers. The Hamilton Depression Rating Scale and the Young Mania Rating Scale were both administered to assess remission of bipolar I disorder, and a self-report scale, the Medication Adherence Rating Scale, was administered to assess medication adherence.

RESULTS

Treatment compliant patients reported that they had received adequate social support and had been sufficiently informed by their physicians about the illness and treatment. Treatment compliant individuals with higher rates of hospitalisations and the results indicate that the number of depressive episodes adversely affects treatment compliance. There was not a statistically significant difference in treatment compliance based on duration of illness, euthymia, time, total number of episodes, age of onset, predominant polarity, drug doses, number of daily medications, frequency of daily medications, or type of mood stabiliser used.

CONCLUSIONS

These results indicate that there are differences between compliant and non-compliant bipolar I disorder patients in terms of adequate social support, information provided by the physician about the illness and treatment, number of depressive episodes and number of hospitalisations.

La psychoéducation pour les troubles bipolaires : recension des écrits et recommandations pour le système de santé québécois

Le trouble bipolaire est une maladie chronique caractérisée par une récurrence des rechutes thymiques, et par des symptômes résiduels interférant avec le fonctionnement de l’individu. La pharmacothérapie demeure la pierre angulaire du traitement. Malheureusement, la médication a des effets limités sur certains aspects de la maladie, sans compter qu’une grande proportion de patients présente des problèmes d’observance à leur traitement pharmacologique. Cette recension des écrits aborde le rôle de la psychoéducation comme traitement complémentaire dans la prise en charge des patients bipolaires. Les différentes modalités de psychoéducation structurée, dont deux programmes psychoéducatifs manualisés appuyés par des données probantes, sont présentées. Dans une perspective de transfert des connaissances, des recommandations pour l’implantation de la psychoéducation dans le système de santé québécois sont proposées.

Effectiveness of six-week psychoeducation program on adherence of patients with bipolar affective disorder

OBJECTIVES

This study examined the effectiveness of a six week psychoeducation program on the adherence of patients with Bipolar Affective Disorder.

METHOD

An experimental study was conducted at a mood disorder outpatient clinic in Zonguldak, Turkiye. Participants were randomly assigned to either intervention (n=35) or control groups (n=36). Both groups were given pre-tests and post-tests to measure their adherence. In the psychoeducation group, the psychoeducation program was provided for 2 h/week for six weeks. In the control group, standard care and information were provided.

RESULTS

After six weeks, the psychoeducation program significantly improved patients' adherence. The treatment adherence rate of the patients in the intervention group increased from 40.0% (14 patients on pre-test), to 86.7% (26 patients on post-test). Meanwhile, the treatment adherence rate of the control group was 38.9% (14 patients) for the pre-test, and 24.2% (8 patients) for the post-test.

CONCLUSION

This controlled trial study demonstrated that a six-week psychoeducation program can be a useful intervention to improve adherence in patients undergoing bipolar affective disorder rehabilitation. More comprehensive mental health outcomes need to be undertaken. Further studies exploring a longer term follow-up are also required.

Six-month outcomes of customized adherence enhancement (CAE) therapy in bipolar disorder

BACKGROUND

There are few psychosocial interventions specifically focused on improved treatment adherence in people with bipolar disorder (BD). Customized adherence enhancement (CAE) is a needs-based, manualized approach intended to improve medication adherence in individuals with BD. This was a six-month prospective trial of a CAE among 43 medication non-adherent individuals with BD who were receiving treatment in a community mental health clinic (CMHC).

METHODS

CAE was flexibly administered in modules applied as indicated by an initial adherence vulnerabilities screening. Screening identified reasons for non-adherence and modules were then administered using pre-set criteria. CAE effects were evaluated at six-week, three-month, and six-month follow-up. The six-month follow-up was our primary time point of interest. The primary outcome was change from baseline in adherence using the Tablets Routine Questionnaire (TRQ) and pill counts. Secondary outcomes included change from baseline in BD symptoms [Hamilton Depression Rating Scale (HAM-D), Young Mania Rating Scale (YMRS), and Brief Psychiatric Rating Scale (BPRS)].

RESULTS

Subjects completed 86% of scheduled sessions, with only two individuals (5%) not participating in any sessions. The number of dropouts at six months was 12 (28%). Mean baseline non-adherence by TRQ was 48% [standard error (SE) 4.8%] missed tablets within the previous week and 51% (4.1%) missed tablets within the previous month. At six-month follow-up, mean TRQ non-adherence improved to 25% (6.8%) missed tablets for the previous week (p = 0.002) and 21% (5.5%) for the previous month (p < 0.001). Symptoms improved, with a change in the baseline mean (SE) BPRS of 43.6 (1.8) versus an endpoint of 36.1 (2.3) (p = 0.001), and baseline mean (SE) HAM-D of 17.8 (1.1) versus an endpoint of 15.3 (1.6) (p = 0.044).

CONCLUSION

CAE was associated with improvements in adherence, symptoms, and functional status. Controlled trials are needed to confirm these preliminary findings.

Observational Studies versus Randomized Controlled Trials of Behavioral Interventions in Field Settings

This article considers research designs that evaluate outcomes of behavioral interventions in field settings. It focuses on differences in efficacy estimates between observational studies (OSs) and randomized controlled trials (RCTs). The article contends that pretreatment motivation and in-treatment compliance both contribute to treatment outcomes. It proposes a 3-variable causal model in which pretreatment motivation produces positive treatment outcomes directly, and also indirectly, via in-treatment compliance. The article challenges the common notion that RCTs represent the gold standard in designs for evaluating the efficacy of behavioral interventions in field settings. The article's causal model predicts that OSs governed by self-assignment and RCTs of the same behavioral interventions both yield biased estimates of efficacy, although these effect-size biases are generally in opposite directions. OS estimates of efficacy are typically too large because of group differences in pretreatment motivation favoring the treated group over the untreated group. RCT efficacy estimates are typically too small because noncompliance in treatment conditions dilutes the impact of field interventions. Taken together, motivation and compliance thus account for the 2 expected efficacy biases: overestimation of effect sizes in OSs and underestimation in RCTs. Accordingly, the causal model predicts that, under most conditions, OSs will generate larger effect sizes than RCTs and thus a higher proportion of significant results. The article examines published outcome evaluations in 3 psychological domains: vocational counseling, precollege academic programs and home-visiting programs. Consistent with the model's directional prediction, studies in all 3 domains document a systematic efficacy difference between OSs and RCTs.

Geriatric bipolar disorder

Because the elderly are the fastest growing segment of the population, the number of older adults with bipolar disorder is increasing. Geriatric bipolar disorder is relatively rare, with an estimated lifetime prevalence of 0.5% to 1%, although approximately 4% to 17% of older patients in clinical psychiatric settings have bipolar disorder. Bipolar elders are disproportionately affected by medical burden. Given the complex nature of this disorder, comorbidity, and behavioral disturbances, various interventions may be indicated, including pharmacotherapies, electroconvulsive therapy, psychotherapies, and integrated care models. Additional research is needed to better understand the epidemiology, phenomenology, and treatment of geriatric bipolar disorder.

Nonadherence in mood disorders: A formidable challenge in clinical practice

Nonadherence in mood disorders poses a significant obstacle to remission and recovery. A comprehensive approach that includes evidence-based strategies have been shown to improve adherence customized to the individual needs of the patient resulting in improved quality of life and reduced disease burden. This is further strengthened by identifying risk factors, establishing therapeutic alliances, and educating patients, families and other healthcare providers.

Adherence according to Mary Poppins: strategies to make the medicine go down

PURPOSE

This article reviews the prevalence, risk factors, and burden of nonadherence in mood and psychotic disorders, and presents evidence-based, disease-specific strategies shown to improve adherence.

CONCLUSION

A comprehensive approach based on the goal of remission, designed around the patient's individual needs, facilitates adherence, leads to improved quality of life, and reduces disease burden.

PRACTICE IMPLICATIONS

Adherence in mood and psychotic disorders can be improved when providers take time to build trusting relationships; identify risk factors; anticipate nonadherence; individualize treatment; and educate patients, families, and other healthcare providers.

Enhancing medication adherence in patients with bipolar disorder

OBJECTIVES

Medication adherence contributes to the efficacy-effectiveness gap of treatment in patients with bipolar disorder. This paper aims to examine the challenges involved in improving medication adherence in bipolar disorder, and to extract some suggestions for future directions from the core psychosocial studies that have targeted adherence as a primary or secondary outcome.

METHODS

A search was conducted for articles that focused on medication adherence in bipolar disorder, with emphasis on publications from 1996 to 2008 using Medline, Web of Science, CINAHL PLUS, and PsychINFO. The following key words were used: adherence, compliance, alliance, adherence assessment, adherence measurement, risk factors, psychosocial interventions, and psycho-education.

RESULTS

There are a number of challenges to understanding non-adherence including the difficulty in defining and measuring it and the various risk factors that need to be considered when aiming to enhance adherence. Nevertheless, the importance of addressing adherence is evidenced by the connection between adherence problems and poor outcome. Despite these challenges, a number of small psychosocial studies targeting adherence as a primary outcome point to the potential usefulness of psycho-education aimed at improving knowledge, attitudes, and adherence behavior, but more large scale randomized controlled trials are needed in this area. Evidence of improved outcomes from larger randomized controlled trials of psychosocial interventions that target medication adherence as a secondary outcome suggests that tackling other factors besides medication adherence may also be an advantage. While some of these larger studies demonstrate an improvement in medication adherence, the translation of these interventions into real life settings may not always be practical. A person centered approach that considers risk factors for non-adherence and barriers to other health behaviors may assist with the development of more targeted briefer interventions. Integral to improving medication adherence is the delivery of psycho-education, and attention needs to be paid to the implementation, and timing of psycho-education. Progress in the understanding of how medicines work may add to the credibility of psycho-education in the future.

CONCLUSIONS

Enhancement of treatment adherence in bipolar patients is a necessary and promising management component as an adjunct to pharmacotherapy. The current literature on psychosocial interventions that target medication adherence in bipolar disorder points to the possibility of refining the concept of non-adherence and adapting psycho-education to the needs of certain subgroups of people with bipolar disorder. Large scale randomized controlled trials of briefer or more condensed interventions are needed that can inform clinical practice.

Bipolar disorder: emotional dysregulation and neuronal vulnerability

Bipolar disorder is clinically characterized by fluctuating affect, and neuropsychologically by impairment in executive functions. Such phenomena are consistent with the centrality of emotional dysregulation and impulsivity to bipolar disorder. They are also consistent with a key role for prefrontal-subcortical (striatal-thalamic) and associated limbic circuitry in its mediation. Furthermore, there is growing data on the cellular mechanisms contributing to neuronal vulnerability in this mediating circuitry.