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De las Cuevas C. Psychiatric Patients' Perceived Health Control and Reactance: Implications for Medication Adherence. Patient Prefer Adherence 2023; 17:1591-1601. [PMID: 37448759 PMCID: PMC10337681 DOI: 10.2147/ppa.s417608] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023] Open
Abstract
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.
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Affiliation(s)
- Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, Universidad de La Laguna, San Cristóbal de La Laguna, Canary Islands, Spain
- Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Canary Islands, Spain
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De las Cuevas C, de Leon J. Self-Report for Measuring and Predicting Medication Adherence: Experts' Experience in Predicting Adherence in Stable Psychiatric Outpatients and in Pharmacokinetics. Patient Prefer Adherence 2020; 14:1823-1842. [PMID: 33116427 PMCID: PMC7555336 DOI: 10.2147/ppa.s242693] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/25/2020] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Carlos De las Cuevas
- Department of Internal Medicine, Dermatology and Psychiatry, University of La Laguna, San Cristóbal de La Laguna, Canary Islands, Spain
- Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, San Cristóbal de La Laguna, Spain
- Correspondence: Carlos De las CuevasDepartment of Internal Medicine, Dermatology and Psychiatry, Universidad de La Laguna,, Campus de Ofra s/n, San Cristóbal de La Laguna, Canary Islands, SpainTel +34-922-316502Fax +34-922-319353 Email
| | - Jose de Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA
- Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
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Clapham E, Bodén R, Brandt L, Jönsson EG, Bahmanyar S, Ekbom A, Ösby U, Reutfors J. Suicide Ideation and Behavior as Risk Factors for Subsequent Suicide in Schizophrenia: A Nested Case-Control Study. Suicide Life Threat Behav 2019; 49:996-1005. [PMID: 30073690 DOI: 10.1111/sltb.12499] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 05/17/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To investigate suicide ideation and behavior as risk factors for suicide in schizophrenia during varying time periods. METHOD Cases were 84 patients who died by suicide within 5 years from diagnosis in a source population of patients discharged for the first time from psychiatric hospitals in Stockholm County, Sweden, with a schizophrenia spectrum diagnosis. One control was individually matched with each suicide case. Data were retrieved from clinical records in a blind fashion. Thoughts of death, thoughts of suicide, suicide plan, and suicide attempt during varying time periods were investigated as risk factors for subsequent completed suicide. RESULTS In adjusted analyses, thoughts of suicide, suicide plan, and suicide attempt were significantly associated with subsequent completed suicide in the following year. The highest suicide risk was found within a year following suicide attempt (adjusted OR 9.9, 95% confidence interval 2.5-39.0). The association between suicide ideation and behavior and subsequent suicide declined over time. CONCLUSIONS Several types of suicide ideation and behavior were associated with suicide, and the association was stronger for suicidal behavior. The clinical significance of suicidal communication appears highest during the following month or/and year. Many suicides occurred without recorded short-term suicidal communication.
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Affiliation(s)
- Eric Clapham
- Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.,Department of Medicine Solna, Centre for Pharmacoepidemiology (CPE), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Robert Bodén
- Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden.,Department of Medicine Solna, Centre for Pharmacoepidemiology (CPE), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lena Brandt
- Department of Medicine Solna, Centre for Pharmacoepidemiology (CPE), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Erik G Jönsson
- Department of Clinical Neuroscience, Centre for Psychiatric Research, Karolinska Institutet, Stockholm, Sweden.,Institute of Clinical Medicine, Psychiatry Section, NORMENT, KG Jebsen Centre for Psychosis Research, University of Oslo, Oslo, Norway
| | - Shahram Bahmanyar
- Department of Medicine Solna, Centre for Pharmacoepidemiology (CPE), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Ekbom
- Department of Medicine Solna, Centre for Pharmacoepidemiology (CPE), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Urban Ösby
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Reutfors
- Department of Medicine Solna, Centre for Pharmacoepidemiology (CPE), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Bright CE. Measuring Medication Adherence in Patients With Schizophrenia: An Integrative Review. Arch Psychiatr Nurs 2017; 31:99-110. [PMID: 28104068 DOI: 10.1016/j.apnu.2016.09.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/24/2016] [Accepted: 09/04/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this paper is to assess the validity, reliability and levels of evidence of existing instruments for measuring medication adherence in patients with schizophrenia. BACKGROUND Schizophrenia is estimated to affect approximately 7 individuals out of 1000 in their lifetimes, with fifty percent of patients attempting suicide. However studies have shown that measuring medication adherence in patients with schizophrenia is difficult and no gold standard currently exists. Without reliable and valid instruments to evaluate non-adherence in this population, research into strategies to improve adherence cannot move forward. DATA SOURCES This integrative review used the following search terms: assessing, measuring, medication adherence, schizophrenia, medication non-adherence, validity, reliability and measures. Databases searched included CINAHL, PubMed, PsycINFO and Scopus). Studies were included if they were published from 2000 to 2016. Fourteen instruments were identified from six studies and were included in this review. RESULTS All the instruments assessed were weak in both validity and reliability coupled with having low levels of evidence. Three instruments (two are fairly new) yielded better validity, reliability and sensitivity; however they have not been assessed in broad, diverse samples, so their generalizability remains unclear. CONCLUSION This study suggests the need to develop an instrument with adequate validity, reliability, and sensitivity to various patients' characteristics.
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Affiliation(s)
- Cordellia E Bright
- Medical University of South Carolina, College of Nursing, Charleston, SC.
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Brain C, Sameby B, Allerby K, Lindström E, Eberhard J, Burns T, Waern M. Twelve months of electronic monitoring (MEMS®) in the Swedish COAST-study: a comparison of methods for the measurement of adherence in schizophrenia. Eur Neuropsychopharmacol 2014; 24:215-22. [PMID: 24359935 DOI: 10.1016/j.euroneuro.2013.11.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 11/24/2013] [Accepted: 11/27/2013] [Indexed: 10/25/2022]
Abstract
The primary aim was to compare objective and subjective measures of adherence in a naturalistic cohort of schizophrenia outpatients over 12 months between October 2008 and June 2011. Antipsychotic medication adherence was monitored in 117 outpatients diagnosed with schizophrenia or schizophrenia-like psychosis according to DSM-IV criteria in a naturalistic prospective study. Adherence was determined by the Medication Event Monitoring System (MEMS®), pill count, plasma levels and patient, staff, psychiatrist and close informant ratings. The plasma level adherence measure reflects adherence to medication and to lab visits. Relationships between MEMS® adherence and other measures were expressed as a concordance index and kappa (K). Non-adherence (MEMS® ≤0.80) was observed in 27% of the patients. MEMS® adherence was highly correlated with pill count (concordance= 89% and K=0.72, p<0.001). Concordance and K were lower for all other adherence measures and very low for the relationship between MEMS® adherence and plasma levels (concordance=56% and K=0.05, p=0.217). Adherence measures were also entered into a principal component analysis that yielded three components. MEMS® recordings, pill count and informant ratings had their highest loadings in the first component, plasma levels alone in the second and patient, psychiatrist and staff ratings in the third. The strong agreement between MEMS® and pill count suggests that structured pill count might be a useful tool to follow adherence in clinical practice. The large discrepancy between MEMS® and the adherence measure based on plasma levels needs further study in clinical settings.
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Affiliation(s)
- Cecilia Brain
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Sweden; Nå Ut-teamet, Psychosis Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Birgitta Sameby
- Nå Ut-teamet, Psychosis Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Katarina Allerby
- Nå Ut-teamet, Psychosis Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Eva Lindström
- Department of Neuroscience, Uppsala University Hospital, Uppsala, Sweden
| | - Jonas Eberhard
- Department of Psychosis Studies, Institute of Psychiatry at the Maudsley, King's College London, United Kingdom
| | - Tom Burns
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, United Kingdom
| | - Margda Waern
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Sweden
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Brain C, Allerby K, Sameby B, Quinlan P, Joas E, Karilampi U, Lindström E, Eberhard J, Burns T, Waern M. Drug attitude and other predictors of medication adherence in schizophrenia: 12 months of electronic monitoring (MEMS(®)) in the Swedish COAST-study. Eur Neuropsychopharmacol 2013; 23:1754-62. [PMID: 24091164 DOI: 10.1016/j.euroneuro.2013.09.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 09/02/2013] [Accepted: 09/05/2013] [Indexed: 11/30/2022]
Abstract
The aim was to investigate clinical predictors of adherence to antipsychotics. Medication use was electronically monitored with a Medication Event Monitoring System (MEMS(®)) for 12 months in 112 outpatients with schizophrenia and schizophrenia-like psychosis according to DSM-IV. Symptom burden, insight, psychosocial function (PSP) and side effects were rated at baseline. A comprehensive neuropsychological test battery was administered and a global composite score was calculated. The Drug Attitude Inventory (DAI-10) was filled in. A slightly modified DAI-10 version for informants was distributed as a postal questionnaire. Non-adherence (MEMS(®) adherence ≤0.80) was observed in 27%. In univariate regression models low scores on DAI-10 and DAI-10 informant, higher positive symptom burden, poor function, psychiatric side effects and lack of insight predicted non-adherence. No association was observed with global cognitive function. In multivariate regression models, low patient-rated DAI-10 and PSP scores emerged as predictors of non-adherence. A ROC analysis showed that DAI-10 had a moderate ability to correctly identify non-adherent patients (AUC=0.73, p<0.001). At the most "optimal" cut-off of 4, one-third of the adherent would falsely be identified as non-adherent. A somewhat larger AUC (0.78, p<0.001) was observed when the ROC procedure was applied to the final regression model including DAI-10 and PSP. For the subgroup with informant data, the AUC for the DAI-10 informant version was 0.68 (p=0.021). Non-adherence cannot be properly predicted in the clinical setting on the basis of these instruments alone. The DAI-10 informant questionnaire needs further testing.
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Affiliation(s)
- Cecilia Brain
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Sweden; Nå Ut-teamet, Psychosis Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Kähärä K, Tulisalo U, Grönlund J, Mattila KJ. Reactions to acute psychotic symptoms in a rural community. Nord J Psychiatry 2013; 67:334-8. [PMID: 23245633 DOI: 10.3109/08039488.2012.745603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Recognition of psychotic disorders constitutes a challenge to the population and health and social care. AIM To evaluate the reactions of the general population, professionals in the health and social services, and local politicians in light of the symptoms of a patient evincing acute psychotic mental symptoms. MATERIAL AND METHODS A postal questionnaire study was conducted in the rural Suupohja area in Finland. Three target groups: a randomized sample of residents aged 15-84 years (n = 1200), local social and healthcare personnel (n = 463) and politicians (n = 148) responded to alternatives in identifying the need and urgency of treatment. RESULTS Seventy-six per cent of residents, 85% of politicians and 87% of health and social employees recognized that the patient was in need of urgent support and treatment. A significant positive association was found in the resident cohort between recognizing urgent need for support and female gender. Forty-eight per cent of inhabitants, 69% of social and healthcare staff, and 65% of politicians estimated that appropriate care and access to care would be obtained in the acute outpatient care of the health centre. CONCLUSION Almost one quarter of residents were not aware of the patient's urgent need for acute mental healthcare. It is a challenge to promote the knowledge and sensitivity of the population in recognizing mental and psychotic symptoms. Also appropriate information is called for regarding local services and how to access the care.
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Affiliation(s)
- Kirsti Kähärä
- Kirsti Kähärä, M.D., Medical Director, Kauhajoki Health Centre , Prännärintie 8, 61800 Kauhajoki , Finland
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Abstract
PURPOSE OF REVIEW Nonadherence to appropriately prescribed medication for psychiatric disorders prevents patients from realizing the full benefits of their treatment and negatively impacts on individuals, their families and the healthcare system. Understanding and reducing nonadherence is therefore a key challenge to quality care for patients with psychiatric disorders. This review highlights findings regarding the prevalence and consequence of nonadherence, barriers to adherence and new intervention methods from 2012 onwards. RECENT FINDINGS Recent research has highlighted that nonadherence is a global challenge for psychiatry and has linked nonadherence to poorer outcomes, including hospital admissions, suicide and mortality. Optimizing medication regimens can reduce nonadherence; however, often a complex interplay of factors affects individuals' motivation and ability to follow their prescription. Psychiatrists can enable patients to develop an accurate model of their illness and treatment and facilitate adherence. However, nonadherence is often a hidden issue within consultations. Novel interventions using new technologies and tailoring techniques may have the potential to reduce nonadherence. SUMMARY Nonadherence remains a significant challenge for patients with psychiatric disorders, physicians and healthcare systems. New developments demonstrate the importance of developing tailored interventions to enable patients to overcome perceptual and practical barriers to adherence.
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