Interventions to Improve Medication Adherence in Patients with Schizophrenia or Bipolar Disorders: A Systematic Review and Meta-Analysis

Interventions to improve medication adherence in persons with mental disorders

PURPOSE OF REVIEW

Nonadherence to medication is prevalent in patients with mental illness. Various factors responsible for it. As a result, there are more hospitalizations, increased risk of suicide and increased cost of care. Thus, there is a need for effective interventions to improve adherence in mentally ill patients.

RECENT FINDINGS

Adherence to medication includes participation of patient in decision making. Interventions in the recent years help patients through techniques like psychoeducation, motivational interviewing and cognitive behaviour therapy. Interventions involve both patients and caregivers. There is a growing body of research about use of technology -based interventions using smart phones, various applications, digital platforms and artificial intelligence. Recent findings of research indicate that a combination of methods of intervention may be more useful in improving adherence. Some conventional interventions yield good results. Robust research is needed in the field of technology- based interventions.

SUMMARY

Non adherence to medication leads to poorer health outcomes and hampers integration of the patient in the society. A collaborative effort of the team of healthcare providers, the patient and caregivers is the way ahead for better adherence and good quality of life.

A realist review of medication optimisation of community dwelling service users with serious mental illness

BACKGROUND

Severe mental illness (SMI) incorporates schizophrenia, bipolar disorder, non-organic psychosis, personality disorder or any other severe and enduring mental health illness. Medication, particularly antipsychotics and mood stabilisers are the main treatment options. Medication optimisation is a hallmark of medication safety, characterised by the use of collaborative, person-centred approaches. There is very little published research describing medication optimisation with people living with SMI.

OBJECTIVE

Published literature and two stakeholder groups were employed to answer: What works for whom and in what circumstances to optimise medication use with people living with SMI in the community?

METHODS

A five-stage realist review was co-conducted with a lived experience group of individuals living with SMI and a practitioner group caring for individuals with SMI. An initial programme theory was developed. A formal literature search was conducted across eight bibliographic databases, and literature were screened for relevance to programme theory refinement. In total 60 papers contributed to the review. 42 papers were from the original database search with 18 papers identified from additional database searches and citation searches conducted based on stakeholder recommendations.

RESULTS

Our programme theory represents a continuum from a service user's initial diagnosis of SMI to therapeutic alliance development with practitioners, followed by mutual exchange of information, shared decision-making and medication optimisation. Accompanying the programme theory are 11 context-mechanism-outcome configurations that propose evidence-informed contextual factors and mechanisms that either facilitate or impede medication optimisation. Two mid-range theories highlighted in this review are supported decision-making and trust formation.

CONCLUSIONS

Supported decision-making and trust are foundational to overcoming stigma and establishing 'safety' and comfort between service users and practitioners. Avenues for future research include the influence of stigma and equity across cultural and ethnic groups with individuals with SMI; and use of trained supports, such as peer support workers.

PROSPERO REGISTRATION NUMBER

CRD42021280980.

Assessing the impact of long-acting injectable compared to oral antipsychotic medications on readmission to a state psychiatric hospital

WHAT IS KNOWN ON THE SUBJECT

People living with schizophrenia spectrum disorder (SSD) have a higher death rate which is caused, in part, by poorer adherence to treatment as compared to those with other mental illnesses. Using long-acting injectable antipsychotic (LAI) medications can improve medication adherence and reduce hospitalizations for people living with SSD but are often underutilized.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

As compared to oral antipsychotic medications provided to patients with SSD at discharge from a psychiatric hospitalization, being provided with an LAI antipsychotic medication may reduce subsequent rehospitalization. Specifically, patients discharged on an atypical or second-generation LAI medication are less likely to be readmitted to the hospital when compared to those discharged on a typical first-generation oral medication.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Because LAI antipsychotic medications are often underutilized as treatment options, the study findings suggest that this modality may be considered for patients with SSD when being discharged from a psychiatric hospitalization. Ideally, psychiatric-mental health nurses can educate patients about indications, benefits, and risks of using atypical or second-generation LAI antipsychotic medications during hospitalization and at discharge prevent the risk for future rehospitalizations.

ABSTRACT

INTRODUCTION: People living with schizophrenia spectrum disorder (SSD) have poorer medication adherence compared to those with other mental illnesses. Long-acting injectable antipsychotic (LAI) medication use is associated with greater adherence, reduced re-hospitalizations, and improved recovery outcomes when compared to oral formulations.

AIM

To compare LAI antipsychotic medication use versus oral formulations on readmission to an inpatient hospital.

METHOD

Medical records (N = 707) from a state psychiatric hospital in the southern region of the United States were reviewed. Controlling for demographic variables, logistic regression analyses were used to examine LAI compared to oral formulations on readmission.

RESULTS

Compared to patients discharged with oral antipsychotic medications, those with LAIs had a lower proportion of readmission rates in 6-month and 1-year periods, but not 30-day or 2-year periods. When controlling for demographic variables, those discharged with an atypical LAI had significantly lower odds of being readmitted within the 24-year period compared to those discharged on a typical oral antipsychotic.

DISCUSSION

Compared to orals, LAIs do not increase and may mitigate readmissions to psychiatric hospitalization.

IMPLICATIONS FOR PRACTICE

Psychiatric-mental health nurses and other professionals may recommend LAIs when indicated for those with SSD.

Pharmacist-led Si-care (schizophrenia care) model to improve medication adherence and symptom management in schizophrenia

Introduction

Schizophrenia is a chronic mental disorder that requires long-term treatment, particularly antipsychotic medications. However, medication adherence among patients with schizophrenia is often suboptimal, leading to symptom relapse and poor outcomes. The Si-Care (Schizophrenia Care) program was developed as a pharmacist-led home intervention to improve medication adherence and support symptom control in patients with schizophrenia. This study aimed to evaluate the effectiveness of the Si-Care intervention in improving medication adherence and maintaining stability of symptoms among schizophrenia patients.

Methods

A quasi-experimental study was conducted in three community health centers or Puskesmas in Banjarmasin, Indonesia. A total of 57 participants were recruited according to the sampling criteria. The Si-Care intervention consisted of seven home visits by trained pharmacists over four months, providing education, counseling, and medication monitoring. Adherence to medication was evaluated using the pill count method and severity of symptoms was measured using the Positive and Negative Syndrome Scale (PANSS) pre- and post-intervention. Data were analyzed using the Friedman test for adherence and the Wilcoxon test for PANSS scores.

Results

Mean medication adherence improved significantly from 77.38 % ± 25.85 at baseline (T0) to 97.57 % ± 11.09 at the final visit (T4) (p = 0.000). However, the decrease in PANSS scores from 38.03 ± 9.14 to 37.81 ± 9.15 was not statistically significant (p = 0.089). Despite the lack of significant change in PANSS scores, symptoms remained stable throughout the intervention, suggesting effective symptom management.

Conclusions

The Si-Care intervention significantly improved medication adherence among people with schizophrenia, contributing to the maintenance of stable symptoms. Pharmacist-led home interventions provide valuable support to address adherence challenges and should be considered a critical component in schizophrenia care. Future studies should consider a more rigorous design, a larger sample size, and longer follow-up to better evaluate the sustainability, scalability, and applicability of the intervention in diverse healthcare settings.

Internalised Stigma, Self-Esteem and Perceived Social Support as Psychosocial Predictors of Quality of Life in Adult Patients with Schizophrenia

Background: Schizophrenia is a chronic and severe mental illness that ultimately leads to reduced quality of life (QoL). Over the years, QoL has emerged as an important outcome in the treatment of schizophrenia patients, but the role of psychosocial variables in determining QoL is still ambiguous. Therefore, in the present research, demographic, clinical and psychosocial variables were examined for their influence on QoL. Methods: We conducted a prospective and cross-sectional study on a sample of 139 patients with schizophrenia (72.7% females, age 48.17 ± 10.22) attending an outpatient service. QoL was measured using Schizophrenia Quality of Life Revision-4 (SQLR4) and internalised stigma, self-esteem, perceived social support, resilience and coping mechanisms were assessed using a battery of standardized self-report scales. Results: Female patients and those less adherent to treatment had reduced cognition and vitality QoL. The worst QoL in all domains was observed in patients with a younger age at illness onset and with six or more hospitalizations. Regression analysis indicated that reduced self-esteem, perceived social support, a larger number of hospitalization and increased internalised stigma predicted poorer overall QoL and accounted for 44.9% in the variance in SQLSR4 global score (adjusted R2 = 0.449, p = 0.046). Conclusions: Routine assessment of internalised stigma, self-esteem and perceived social support, in addition to demographic and clinical variables and addressing possible deficits in these areas through personalized intervention, could improve QoL in schizophrenia patients.

Nomogram model for predicting medication adherence in patients with various mental disorders based on the Dryad database

OBJECTIVE

Treatment compliance among psychiatric patients is related to disease outcomes. How to assess patient compliance remains a concern. Here, we established a predictive model for medication compliance in patients with psychotic disorders to provide a reference for early intervention in treatment non-compliance behaviour.

DESIGN

Clinical information for 451 patients with psychotic disorders was downloaded from the Dryad database. The Least Absolute Shrinkage and Selection Operator regression and logistic regression were used to establish the model. Bootstrap resampling (1000 iterations) was used for internal validation and a nomogram was drawn to predict medication compliance. The consistency index, Brier score, receiver operating characteristic curve and decision curve were used for model evaluation.

SETTING

35 Italian Community Psychiatric Services.

PARTICIPANTS

451 patients prescribed with any long-acting intramuscular (LAI) antipsychotic were consecutively recruited, and assessed after 6 months and 12 months, from December 2015 to May 2017.

RESULTS

432 patients with psychotic disorders were included for model construction; among these, the compliance rate was 61.3%. The Drug Attitude Inventory-10 (DAI-10) and Brief Psychiatric Rating Scale (BPRS) scores, multiple hospitalisations in 1 year and a history of long-acting injectables were found to be independent risk factors for treatment noncompliance (all p<0.01). The concordance statistic of the nomogram was 0.709 (95% CI 0.652 to 0.766), the Brier index was 0.215 and the area under the ROC curve was 0.716 (95% CI 0.669 to 0.763); decision curve analysis showed that applying this model between the threshold probabilities of 44% and 63% improved the net clinical benefit.

CONCLUSION

A low DAI-10 score, a high BPRS score, multiple hospitalisations in 1 year and the previous use of long-acting injectable drugs were independent risk factors for medication noncompliance in patients with psychotic disorders. Our nomogram for predicting treatment adherence behaviour in psychiatric patients exhibited good sensitivity and specificity.

Types of Medication Non-adherence & Approaches to Enhance Medication Adherence in Mental Health Disorders: A Narrative Review

Background

Medication non-adherence (MNA) presents a significant obstacle that negatively impacts treatment effectiveness in mental health disorders. The objective of this review is to study different types of MNA and interventions designed to enhance medication adherence among individuals with mental health disorders.

Methods

We conducted an electronic search on PubMed and Google Scholar using keywords such as adherence, non-adherence, compliance, non-compliance, mental health disorders, psychotropic drugs, major depressive disorder (MDD), schizophrenia, anxiety disorders, and bipolar disorders (BD). From the search results, we selected studies pertinent to the objective of the review.

Results

Non-adherence can be categorized into primary nonadherence (not starting medication) and secondary non-adherence (not taking the medication as directed). Generally, we can group the reasons for non-adherence into unintentional and intentional. Unintentional non-adherence (UNA) arises when patients genuinely desire to comply with their prescribed course of therapy but are hindered by factors beyond their control. When addressing UNA, interventions should simplify medication regimens, utilize long-acting injectable (LAIs) medications, offer tools to manage medication and provide follow-up reminders. When a patient deliberately decides not to follow their treatment plan, this is known as intentional non-adherence. To improve intentional non-adherence, the focus should be on patient-centred care and shared decision-making, psychoeducation, effective doctor-patient communication, cognitive-behavioral strategies, and addressing concerns related to the side effects of psychotropic drugs.

Conclusion

It is crucial to understand that there is no universal solution to address non-adherence in mental health disorders. Each patient has distinct needs and characteristics, making personalized strategies and interventions of utmost significance.

Interventions for improving adherence to psychological treatments for common mental disorders: a systematic review

Our systematic review aims to synthesise the evidence on interventions targeting improvement in patient adherence to psychological treatments for common mental disorders. A search was conducted on six electronic databases using search terms under the following concepts: common mental disorders, adherence, psychological treatments and controlled trial study design. Due to the heterogeneity in intervention content and outcomes evaluated in the included studies, a narrative synthesis was conducted. Risk of bias was assessed using the Cochrane Risk of Bias Version 2 tool for randomised controlled trials and the Cochrane ROBINS-I tool for non-randomised controlled trials. The search yielded 23 distinct studies with a total sample size of 2,779 participants. All studies were conducted in high-income or upper-middle-income countries. Interventions to improve patient adherence to psychological treatments included reminders and between-session engagement (e.g., text messages), motivational interviewing, therapy orientation (e.g., expectation-setting) and overcoming structural barriers (e.g., case management). Interventions from 18 out of 23 studies were successful in improving at least one primary adherence outcome of interest (e.g., session attendance). Some studies also reported an improvement in secondary outcomes - six studies reported an improvement in at least one clinical outcome (e.g., depression), and three studies reported improvements in at least one measure of well-being or disability (e.g., days spent in in-patient treatment). By incorporating these interventions into psychological treatment services, therapists can better engage with and support their patients, potentially leading to improved mental health outcomes and overall well-being.

Medication Adherence and Its Relationship With Quality of Life and Functionality in Individuals With Bipolar Disorder: A Cross-Sectional Correlational Study

PURPOSE

The current cross-sectional correlational study aimed to determine the relationship of medication adherence with functionality and quality of life in individuals with bipolar disorder (BD).

METHOD

The research was conducted with 141 individuals with BD followed as outpatients. Data were collected using an information form, Morisky Medication Adherence Scale (MMAS), Quality of Life in Bipolar Disorder Scale (QoL.BD), and Bipolar Disorder Functioning Questionnaire (BDFQ).

RESULTS

A significant positive correlation was found between participants' MMAS total score and QoL.BD (p < 0.001) and BDFQ (p < 0.05) scores. A significant positive correlation was also found between QoL.BD and BDFQ scores (p < 0.001).

CONCLUSION

Medication compliance positively affects quality of life and social functionality in individuals with BD. Thus, interventions to increase medication adherence are recommended. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].

Neurostructural changes in schizophrenia and treatment-resistance: a narrative review

Schizophrenia is a complex disorder characterized by multiple neurochemical abnormalities and structural changes in the brain. These abnormalities may begin before recognizable clinical symptoms appear and continue as a dynamic process throughout the illness. Recent advances in imaging techniques have significantly enriched our comprehension of these structural alterations, particularly focusing on gray and white matter irregularities and prefrontal, temporal, and cingulate cortex alterations. Some of the changes suggest treatment resistance to antipsychotic medications, while treatment nonadherence and relapses may further exacerbate structural abnormalities. This narrative review aims to discuss the literature about alterations and deficits within the brain, which could improve the understanding of schizophrenia and how to interpret neurostructural changes.

A randomized controlled trial of an acceptance-based, insight-inducing medication adherence therapy (AIM-AT) for adults with early-stage psychosis

This study aimed to test the effectiveness of an acceptance-based medication adherence intervention for people with early-stage psychosis. An assessor-blind, three-arm randomized controlled trial design was used. One hundred and twenty-six participants who were adults with ≤3 years of psychosis were recruited from four district Integrated Community Centers for Mental Wellness in Hong Kong. They were randomly assigned to receive a 10-session acceptance-based, insight-inducing medication adherence therapy (AIM-AT) intervention, a conventional psychoeducation group program, or usual treatment (n = 42 per group). Primary outcomes were medication adherence and insight into the illness/treatment. All study outcomes were measured at recruitment and immediately, 6 months, and 12 months post-intervention. Participants in the AIM-AT experienced statistically significant improvements in the primary outcomes (levels of medication adherence and insight into illness/treatment), when compared to those in the other two groups over the 12-month follow-ups. The AIM-AT group also had significantly greater improvements in psychotic symptoms, psychosocial functioning, service satisfaction, length of rehospitalization, and total number of patients hospitalized over the follow-up period. These findings support the effectiveness of the AIM-AT to improve medication adherence, psychosocial health, and service satisfaction in people with early-stage psychosis.

Predictors of adherence to exercise interventions in people with schizophrenia

Exercise interventions are nowadays considered as effective add-on treatments in people with schizophrenia but are usually associated with high dropout rates. Therefore, the present study investigated potential predictors of adherence from a large multicenter study, encompassing two types of exercise training, conducted over a 6-month period with individuals with schizophrenia. First, we examined the role of multiple participants' characteristics, including levels of functioning, symptom severity, cognitive performance, quality of life, and physical fitness. Second, we used K-means clustering to identify clinical subgroups of participants that potentially exhibited superior adherence. Last, we explored if adherence could be predicted on the individual level using Random Forest, Logistic Regression, and Ridge Regression. We found that individuals with higher levels of functioning at baseline were more likely to adhere to the exercise interventions, while other factors such as symptom severity, cognitive performance, quality of life or physical fitness seemed to be less influential. Accordingly, the high-functioning group with low symptoms exhibited a greater likelihood of adhering to the interventions compared to the severely ill group. Despite incorporating various algorithms, it was not possible to predict adherence at the individual level. These findings add to the understanding of the factors that influence adherence to exercise interventions. They underscore the predictive importance of daily life functioning while indicating a lack of association between symptom severity and adherence. Future research should focus on developing targeted strategies to improve adherence, particularly for people with schizophrenia who suffer from impairments in daily functioning.Clinical trials registration The study of this manuscript which the manuscript is based was registered in the International Clinical Trials Database, ClinicalTrials.gov (NCT number: NCT03466112, https://clinicaltrials.gov/ct2/show/NCT03466112?term=NCT03466112&draw=2&rank=1 ) and in the German Clinical Trials Register (DRKS-ID: DRKS00009804.

Technology-Based Strategy to Improve Medication Compliance Among Patients With Schizophrenia Spectrum Disorders

INTRODUCTION

 Non-compliance to medications remains a challenging problem in schizophrenia. Newer strategies with high feasibility and acceptability are always being researched. This study aimed to assess the effectiveness of technology-based intervention in improving medication compliance in individuals with schizophrenia.

METHOD

This was a prospective intervention study where participants were required to use the SuperMD smartphone application (Digital-Health Technologies Pte Ltd, Kuala Lumpur, Malaysia) for a month. A change in the Medication Adherence Rating Scale-Malay Translation (MARS-M) and Malay Translation of Drug Adherence Inventory-9 (MDAI-9) scores indicated a change in compliance and attitude to medication. Positive and Negative Syndrome Scale (PANSS) was used to assess change in symptoms and insight. Medication compliance was also obtained from the SuperMD application. Paired T-test was used to evaluate the significance of changes in mean scores of research variables over the study period. Wilcoxon signed-rank test was used to analyze the subscale of MDAI-9 and the change in PANSS score. The Kruskal-Wallis test was used to determine the effect of the change of insight on the level of compliance with medication.

RESULTS

There were 36 participants in this study. The results showed statistically significant improvement in compliance (0.65, p ≤ 0.01) but not in attitude towards medication (0.78, p = 0.065). There was also an improvement in PANNS score (-2.58, P ≤ 0.01). There was no significant change in insight (χ2(2) = 3.802, p = 0.15).  Conclusion:The use of technology-based strategies like SuperMD is effective in improving medication compliance for individuals with schizophrenia.

Coping strategies and adherence in people with mood disorder: a cross-sectional study

Introduction

Non-adherence to treatment recommendations is a significant problem, as it contributes to the progression of the disease and to the exacerbation of distressing symptoms. Failure to cope with the disease and elevated levels of stress, in turn, influence the choice of strategy for coping with a difficult situation, and thus adherence to recommendations.

Objectives

The purpose of our study was to evaluate the impact of the subjects' stress coping styles on therapeutic adherence, life satisfaction, disease acceptance and quality of life (QoL) in people with mood disorders.

Methods

This survey-based study included 102 respondents diagnosed with mood disorders, living in the West Pomeranian Voivodeship. It was performed using the sociodemographic questionnaire and standardized tools: The Coping Inventory for Stressful Situations (CISS), The Satisfaction with Life Scale (SWLS), The Short Form-36 (SF-36) Health Survey, The Adherence to Refills and Medication Scale (ARMS), and The Acceptance of Illness Scale (AIS).

Results

Some 47.06% of the respondents suffered from depressive disorders, while 34.31% had depression or mixed anxiety disorder. Patients who made greater use of an emotion-focused style were found to have significantly lower life satisfaction than other patients. Moreover, this style was related to such SF-36 domains as general health, social functioning, role emotional, vitality, and mental health, as well as to physical component summary (PCS) and mental component summary (MCS).

Conclusion

Treatment non-adherence is a serious challenge in the treatment of patients with mood disorders. Individuals who do not adequately follow treatment recommendations often resort to alternative activities as a mechanism for coping with difficult situations. Patients who predominantly adopt an emotion-oriented coping style tend to experience lower life satisfaction and greater difficulty accepting their condition compared to their peers. Conversely, patients who adopt a task-oriented coping style report better quality of life than those who rely on emotion-oriented coping or alternative activities.

Effects of Social Support on Medication Adherence Among Patients with Schizophrenia: Serial Multiple Mediation Model

Purpose

This study aims to explore the serial mediating effect of stigma and depression on the association between social support and medication adherence.

Patients and Methods

A cross-sectional survey was undertaken in the Changning District of Shanghai using a five-part questionnaire from August to December 2023. A convenient sampling method was employed, and 35 patients with schizophrenia were invited from each of the 9 streets in Changning District to participate in the survey, resulting in a total of 305 valid questionnaires collected. The questionnaire measured social support, stigma, depression, medication adherence, and demographic characteristics. Data analysis involved descriptive statistics, independent samples t-tests, ANOVA, Pearson correlation analysis, and the bootstrap method.

Results

There was a direct and significantly positive association between social support and medication adherence (β = 0.69, p < 0.001). Moreover, increased levels of stigma (β = - 0.45, p = 0.013) and depression (β = - 0.09, p = 0.017) were both associated with a decline in medication adherence. Bootstrapping analysis revealed that the association between social support and medication adherence operated indirectly through stigma (β = 0.11, 95% CI: 0.03, 0.18). Additionally, social support was indirectly associated with medication adherence through depression (β = 0.15, 95% CI: 0.04, 0.30). Further analysis indicated that social support had an indirect association with medication adherence through both stigma and depression (β = 0.04, 95% CI: 0.01, 0.07).

Conclusion

Stigma and depression serially mediate the association between social support and medication adherence among patients with schizophrenia. This serial multiple mediation model underscores the importance of integrating social support interventions with psychological interventions aimed at reducing stigma and depression, thereby effectively enhancing medication adherence in patients with schizophrenia.

A Hybrid Type 1 trial of a multi-component mHealth intervention to improve post-hospital transitions of care for patients with serious mental illness: Study protocol

BACKGROUND

The transition from acute (e.g., psychiatric hospitalization) to outpatient care is associated with increased risk for rehospitalization, treatment disengagement, and suicide among people with serious mental illness (SMI). Mobile interventions (i.e., mHealth) have the potential to increase monitoring and improve coping post-acute care for this population. This protocol paper describes a Hybrid Type 1 effectiveness-implementation study, in which a randomized controlled trial will be conducted to determine the effectiveness of a multi-component mHealth intervention (tFOCUS) for improving outcomes for adults with SMI transitioning from acute to outpatient care.

METHODS

Adults meeting criteria for schizophrenia-spectrum or major mood disorders (n = 180) will be recruited from a psychiatric hospital and randomized to treatment-as-usual (TAU) plus standard discharge planning and aftercare (CHECK-IN) or TAU plus tFOCUS. tFOCUS is a 12-week intervention, consisting of: (a) a patient-facing mHealth smartphone app with daily self-assessment prompts and targeted coping strategies; (b) a clinician-facing web dashboard; and, (c) mHealth aftercare advisors, who will conduct brief post-hospital clinical calls with patients (e.g., safety concerns, treatment engagement) and encourage app use. Follow-ups will be conducted at 6-, 12-, and 24-weeks post-discharge to assess primary and secondary outcomes, as well as target mechanisms. We also will assess barriers and facilitators to future implementation of tFOCUS via qualitative interviews of stakeholders and input from a Community Advisory Board throughout the project.

CONCLUSIONS

Information gathered during this project, in combination with successful study outcomes, will inform a potential tFOCUS intervention scale-up across a range of psychiatric hospitals and healthcare systems.

CLINICALTRIALS

govregistration: NCT05703412.

Attitudes of patients with schizophrenia spectrum or bipolar disorders towards medication self-management during hospitalisation

BACKGROUND

Medication self-management (MSM) is defined as a person's ability to cope with medication treatment for a chronic condition, along with the associated physical and psychosocial effects that the medication causes in their daily lives. For many patients, it is important to be able to self-manage their medication successfully, as they will often be expected to do after discharge.

AIM

The aim of this study was to describe the willingness and attitudes of patients with schizophrenia spectrum or bipolar disorders regarding MSM during hospital admission. A secondary aim was to identify various factors associated with patient willingness to participate in MSM and to describe their assumptions concerning needs and necessary conditions, as well as their attitudes towards their medication.

METHODS

A multicentre, quantitative cross-sectional observational design was used to study the willingness and attitudes of psychiatric patients regarding MSM during hospitalisation. The study adhered to guidelines for Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

RESULTS

In this study, 84 patients, of which 43 were patients with schizophrenia spectrum disorders and 41 were patients with bipolar disorders, participated. A majority of the patients (81%) were willing to participate in MSM during their hospitalisation. Analysis revealed patients are more willing to MSM if they are younger (r = -.417, p < .001) and a decreasing number of medicines (r = -.373, p = .003). Patients' willingness was positively associated with the extent of support by significant others during and after hospitalisation (Pearson's r = .298, p = .011). Patients were convinced that they would take their medication more correctly if MSM were to be allowed during hospitalisation (65%).

CONCLUSION

Most of the patients were willing to self-manage their medication during hospitalisation, however, under specific conditions such as being motivated to take their medication correctly and to understand the benefits of their medication.

RELEVANCE TO CLINICAL PRACTICE

From a policy point of view, our study provided useful insights into how patients look at MSM to enable the development of future strategies. Since patients are willing to self-manage their medication during hospitalisation, this may facilitate its implementation.

PATIENT CONTRIBUTION

Patients were recruited for this study. Participation was voluntary, and signed informed consent was obtained from all participants prior to the questionnaire.

A Case of Risperidone-Induced Urinary Incontinence

Schizophrenia spectrum disorders are psychiatric conditions associated with an increased risk of all-cause mortality; patients with these conditions have a shortened average lifespan compared to the general population. First-line treatment for schizophrenia spectrum illness consists of atypical antipsychotics, which are associated with well-understood side effects, including metabolic syndrome, anticholinergic effects, and extrapyramidal symptoms. We are presenting a case of a 36-year-old patient treated with the atypical antipsychotic risperidone who experienced treatment-associated urinary incontinence. In the current literature, atypical antipsychotic-induced urinary incontinence is not well-documented in patients with schizophrenia spectrum disorder. Incontinence is often a topic of societal shame for many patients, and as a side effect, it may influence medication compliance. In the treatment of schizophrenia spectrum disorders, compliance is essential to prevent psychosis relapse in patients, so prescribers must be aware of this potential side effect and how to manage it. Upon a patient presenting with incontinence suspected to be due to atypical antipsychotics, other more common causes of incontinence must first be ruled out. Then, further management can consist of stopping the offending medication or adding a medication to address the incontinence. In this case, our patient had an extended history of suboptimal treated schizoaffective disorder, and risperidone was providing significant improvement; therefore, to ensure continued improvement, we initiated oxybutynin to manage urinary incontinence.

The relationship between biological rhythm and perceived social support, coping styles and medication adherence in patients with bipolar disorder in Türkiye

INTRODUCTION

The disruption of biological rhythm (sleep, eating patterns, hormonal secretions, activities, and social life etc.) in individuals diagnosed with bipolar disorder makes it challenging to balance the mood of the patient and facilitates recurrence. Although social support, coping with stress, and medication adherence are known to affect prognosis, no study has been found to investigate the relationship between these factors and biological rhythm.

AIM

This descriptive and correlational design study investigated the relationship between perceived social support, coping styles and medication adherence, and biological rhythm in individuals diagnosed with bipolar disorder.

METHOD

This study was conducted with 111 patients receiving treatment in the outpatient clinics of the psychiatry department of two public hospitals in Ankara, Turkey. Biological Rhythm Interview of Assessment in Neuropsychiatry (BRIAN), Multidimensional Scale of Perceived Social Support (MSPSS), Coping Style Inventory (CSI), and Morisky Medication Adherence Scale (MMAS) were used for data collection.

RESULTS

The biological rhythm total and subscales scores were significantly and negatively related to perceived social support total, and subscales scores (p < 0.005). The biological rhythm total and most of its subscales scores were significantly and negatively related to medication adherence (p < 0.005). The biological rhythm total and domain scores were significantly and negatively related to seeking social support, self-confident, and optimistic subscales of CSI while significantly and positively related to helpless and submissive (p < 0.005).

DISCUSSION

In this study, a positive relationship was found between increased perceived social support, effective coping with stress, and adherence to medication. This study highlights that these factors may be helpful for the regulation of biological rhythm.

Physical activity influences adherence to pharmacological treatments in patients with severe mental disorders: results from the multicentric, randomized controlled LIFESTYLE trial

Introduction: Poor adherence to pharmacological treatment is frequent in people with severe mental disorders and it often causes lack of effectiveness of many psychotropic drugs. Thus, efforts should be made to improve adherence to pharmacological treatments in patients with these disorders. Methods: In this paper, based on the LIFESTYLE randomized, controlled multicentric trial, we aim to: 1) assess the level of adherence in a real-world sample of patients with severe mental disorders; 2) evaluate differences in treatment adherence according to patients' socio-demographic and clinical characteristics; 3) evaluate the impact of an innovative psychosocial intervention, on patients' adherence to treatments. The Lifestyle Psychosocial Group Intervention consists of group sessions, focused on different lifestyle behaviours, including healthy diet; physical activity; smoking habits; medication adherence; risky behaviours; and regular circadian rhythms. At end of each session a 20-min moderate physical activity is performed by the whole group. Results: The sample consists of 402 patients, mainly female (57.1%, N = 229), with a mean age of 45.6 years (±11.8). Less than 40% of patients reported a good adherence to pharmacological treatments. Adherence to treatments was not influenced by gender, age, diagnosis and duration of illness. At the end of the intervention, patients receiving the experimental intervention reported a significant improvement in the levels of adherence to treatments (T0: 35.8% vs. T3: 47.6%, p < 0.005). Patients practicing moderate physical activity reported a two-point improvement in the levels of adherence [odds ratio (OR): 1,542; 95% confidence intervals (CI): 1,157-2,055; p < 0.001], even after controlling for several confounding factors. Discussion: The experimental lifestyle intervention, which can be easily implemented in the routine clinical practice of mental health centres, was effective in improving adherence to pharmacological treatments.

Digital health interventions to improve adherence to oral antipsychotics among patients with schizophrenia: a scoping review

OBJECTIVES

To assess the current evidence on the potential of digital health interventions (DHIs) to improve adherence to oral antipsychotics among patients with schizophrenia by assessing the methodologies, feasibility and effectiveness of DHIs as well as the perceptions of relevant stakeholders.

DESIGN

The scoping review was conducted based on the methodologies outlined by Levac et al and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines.

DATA SOURCES

PubMed, Embase, Web of Science, Scopus, CINAHL, PsycINFO and the Cochrane Library were searched in August 2023 to identify relevant publications from the previous decade.

ELIGIBILITY CRITERIA

Studies published in English focused on improving medication adherence among adult patients with schizophrenia or schizoaffective disorder via DHIs were selected. Protocols, editorials, comments, perspectives, reviews, correspondence and conference abstracts were excluded.

DATA EXTRACTION AND SYNTHESIS

The extracted data included general information about the study, framework, participants, features and strategies of DHIs, measurement tools for adherence used, and main findings.

RESULTS

In total, 64 studies were included in the qualitative synthesis. Features used in DHIs to improve medication adherence included phone calls, text messages, mobile apps, sensors, web-based platforms and electronic devices. Strategies included medication reminders and monitoring, providing medication-related information and suggestions, other illness management suggestions and individual support. Texting and mobile apps were commonly used as medication reminders and monitoring methods. Additionally, the use of sensors combined with other digital technologies has garnered significant attention. All the interventions were considered acceptable and feasible, and several were assessed in pilot trials. Preliminary findings suggest that DHIs could enhance medication adherence in patients with schizophrenia. However, further validation of their effectiveness is required.

CONCLUSION

DHIs are a promising approach to enhancing medication adherence among patients with schizophrenia. Future interventions should be interactive, focusing on user preference, experience and privacy.

Evaluation of psychometric properties of a leaflet developed for schizophrenia

BACKGROUND

Patients with severe mental illnesses like schizophrenia may benefit from a variety of patient education materials. Despite the availability of various resources, it is essential to assess the extent to which patients can comprehend the materials provided.

OBJECTIVE

This study aims to evaluate the reliability and readability of the patient information leaflet (PIL) for schizophrenia.

METHOD

A quasi-experimental study was conducted for a period of 6 months in the departments of psychiatry. Patients with a diagnosis of schizophrenia were recruited for the study. A user-testing questionnaire was developed and validated with the help of an expert committee to assess reliability. Later, translated versions of the questionnaire were then administered to the patients based on their language preference and evaluated by test-retest analysis. The readability was assessed using pre-validated and translated versions of the PIL. Initially, baseline scores of patient knowledge were assessed using a reliable user-testing questionnaire. Later, their responses were reassessed again using the same questionnaire after reading the PIL.

RESULTS

A total of 45 patients participated in the study. From the total sample, 20 participants were randomly selected for reliability assessment. Intraclass-correlation coefficient (ICC), a statistical tool of reliability, give .6 for Kannada, .7 for Malayalam and 1 for the English version of the questionnaire. The overall patient's knowledge was found to be improved from 50.4 to 76.4 after reading the PIL.

CONCLUSION

Patients with schizophrenia were able to comprehend the information available on the PIL. Therefore, further research is needed to determine its efficacy in a larger population.

Myxedema Coma Precipitated by Sepsis in a Patient With a Complex Mental Health History

Myxedema coma is a rare and life-threatening manifestation of severe hypothyroidism. Myxedema refers to altered mental status observed in these patients. Clinical characteristics observed include hypothermia, bradycardia, respiratory failure, hyponatremia, and altered mental status. We present the case of a 57-year-old female who was brought into the hospital with a history of collapse and a long lie. On initial assessment, she was hypothermic, hypotensive, bradycardic, and hypoglycemic with elevated infection markers, acute kidney injury, and electrolyte derangement. Her thyroid function tests on admission were severely impaired with a TSH (thyroid stimulating hormone) level of 144.46 mU/L and Free T4 (thyroxine) levels of 3.4 pmol/L. She was admitted to the intensive care unit and was started on intravenous antibiotics, intravenous liothyronine, oral levothyroxine, and intravenous hydrocortisone. Initially, her hypothermia and bradycardia were slow to respond to treatment measures, but following the introduction of liothyronine, she showed marked improvement. Over the next few days, her infection markers improved, her acute kidney injury resolved, and her thyroid function tests normalized. Liothyronine was stopped after 6 days, levothyroxine was continued at her regular dose of 175 micrograms, and she was safely discharged with outpatient endocrinology follow-up.

The attitude of healthcare providers towards medication self-management in hospitalized patients diagnosed with schizophrenia or bipolar disorders

BACKGROUND

Medication self-management (MSM) is considered an important aspect of pharmacotherapy and plays an essential role in the treatment of various illnesses. To date, research into the willingness and attitude of psychiatric healthcare providers toward MSM in patients diagnosed with schizophrenia or bipolar disorders during hospitalization is lacking.

AIM

The aim of this study was to identify healthcare providers' willingness to MSM and assess their attitude, conditions, benefits, and ability toward it during hospitalization.

METHODS

A multicenter, quantitative cross-sectional observational design was used to study psychiatric healthcare providers' attitude to MSM during hospitalization in patients diagnosed with schizophrenia or bipolar disorders.

RESULTS

In this study, 173 healthcare providers, of which 147 were nurses and 26 psychiatrists, participated. During hospitalization, 86% of the healthcare providers were willing to MSM. Regularly evaluating patients' ability regarding MSM during hospitalization was seen as an important condition (94%). Psychiatrists were significantly less convinced that MSM during hospitalization has a positive impact on adherence when compared to nurses (respectively 54% vs. 77%, p = .009).

DISCUSSION

Most healthcare providers indicated that they were willing to MSM in patients diagnosed with schizophrenia or bipolar disorders during hospitalization under specific conditions.

Offenders and non-offenders with schizophrenia spectrum disorders: Do they really differ in known risk factors for aggression?

Introduction

Individuals with schizophrenia spectrum disorders (SSD) have an elevated risk for aggressive behavior, and several factors contributing to this risk have been identified, e. g. comorbid substance use disorders. From this knowledge, it could be inferred that offender patients show a higher expression of said risk factors than non-offender patients. Yet, there is a lack of comparative studies between those two groups, and findings gathered from one of the two are not directly applicable to the other due to numerous structural differences. The aim of this study therefore was to identify key differences in offender patients and non-offender patients regarding aggressive behavior through application of supervised machine learning, and to quantify the performance of the model.

Methods

For this purpose, we applied seven different (ML) algorithms on a dataset comprising 370 offender patients and a comparison group of 370 non-offender patients, both with a schizophrenia spectrum disorder.

Results

With a balanced accuracy of 79.9%, an AUC of 0.87, a sensitivity of 77.3% and a specificity of 82.5%, gradient boosting emerged as best performing model and was able to correctly identify offender patients in over 4/5 the cases. Out of 69 possible predictor variables, the following emerged as the ones with the most indicative power in distinguishing between the two groups: olanzapine equivalent dose at the time of discharge from the referenced hospitalization, failures during temporary leave, being born outside of Switzerland, lack of compulsory school graduation, out- and inpatient treatment(s) prior to the referenced hospitalization, physical or neurological illness as well as medication compliance.

Discussion

Interestingly, both factors related to psychopathology and to the frequency and expression of aggression itself did not yield a high indicative power in the interplay of variables, thus suggesting that while they individually contribute to aggression as a negative outcome, they are compensable through certain interventions. The findings contribute to our understanding of differences between offenders and non-offenders with SSD, showing that previously described risk factors of aggression may be counteracted through sufficient treatment and integration in the mental health care system.

Cyclothymic Temperament, Physical Neglect, and Earlier Age of Onset Predict Poor Medication Adherence in Patients With Bipolar Disorder

ABSTRACT

Individual-level risk factors may predict poor medication adherence (PMA) in bipolar disorder (BD). This study aimed to evaluate the association between affective temperament, childhood trauma, age of first onset, and PMA in patients with BD in China. A total of 168 patients completed the eight-item Morisky Medication Adherence Scale; the Short Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire; and the Childhood Trauma Questionnaire-Short Form. Scores were then compared between PMA and non-PMA groups. Binary logistic regression showed that age of first onset was negatively correlated with PMA ( β = -0.106, p = 0.002), whereas physical neglect and cyclothymic temperament were positively correlated with PMA ( β = 0.143, p = 0.029; β = 0.19, p = 0.001, respectively). These findings indicate that cyclothymic temperament, physical neglect, and earlier onset are predictors of PMA in patients with BD and that such patients may require further attention to improve medical compliance.

A Systematic Review and Meta-Analysis of the Effectiveness of Adherence Therapy and Its Treatment Duration in Patients with Schizophrenia Spectrum Disorders

BACKGROUND

Adherence therapy (AT) is an intervention for improving medication adherence of people with schizophrenia spectrum disorders, but no systematic reviews have yet summarized the effectiveness and minimum treatment duration of AT. We here aimed to systematically examine the effectiveness of AT in improving outcomes versus treatment as usual (TAU) and its minimum effective duration for people diagnosed with schizophrenia spectrum disorders.

PATIENTS AND METHODS

Eligible randomized controlled trials were identified from four databases (Web of Science, PubMed, CINAHL and Cochrane Library) for the period 1 January 2006 to 1 January 2023. Of 1087 retrieved candidate studies, five studies with a total of 726 participants met the inclusion criteria. The search terms consisted of adherence therapy, compliance therapy, schizophrenia, schizoaffective disorder, schizophrenic disorder, medication adherence, and medication compliance (combined with OR and AND). Two investigators independently selected studies, extracted data, and conducted bias risk assessments. Random-effects models were used to analyze the pooled data.

RESULTS

Meta-analysis of the five selected studies showed that AT had a significantly greater positive effects than TAU on psychiatric symptoms, but no significant effects on adherence behaviors and attitudes.

CONCLUSION

The AT had limited effects in terms of improving the attitudes and behaviors of people with schizophrenia spectrum disorders with respect to medication adherence, but did improve patients' psychiatric symptoms. The therapy should be performed by trained staff for maximum benefit, and the recommended duration of the intervention is 12 hours.

Strategies and Tools for Supporting the Appropriateness of Drug Use in Older People

Through this structured review of the published literature, we aimed to provide an up-to-date description of strategies (human-related) and tools (mainly from the digital field) facilitating the appropriateness of drug use in older adults. The evidence of each strategy and tool's effectiveness and sustainability largely derives from local and heterogeneous experiences, with contrasting results. As a general framework, three main steps should be considered in implementing measures to improve appropriateness: prescription, acceptance by the patient, and continuous monitoring of adherence and risk-benefit profile. Each step needs efforts from specific actors (physicians, patients, caregivers, healthcare professionals) and dedicated supporting tools. Moreover, how to support the appropriateness also strictly depends on the particular setting of care (hospital, ambulatory or primary care, nursing home, long-term care) and available economic resources. Therefore, it is urgent assigning to each approach proposed in the literature the following characteristics: level of effectiveness, strength of evidence, setting of implementation, needed resources, and issues for its sustainability.

Effectiveness of interventions to improve medication adherence in adults with depressive disorders: a meta-analysis

BACKGROUND

Non-adherence to medication is a major obstacle in the treatment of depressive disorders. We systematically reviewed the literature to evaluate the effectiveness of interventions aimed at improving adherence to medication among adults with depressive disorders with emphasis on initiation and implementation phase.

METHODS

We searched Medline, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, Social Science Citation Index and Science Citation Index for randomized or non-randomized controlled trials up to January 2022. Risk of bias was assessed using the criteria of the Cochrane Collaboration. Meta-analyses, cumulative and meta-regression analyses for adherence were conducted.

RESULTS

Forty-six trials (n = 24,324) were included. Pooled estimate indicates an increase in the probability of adherence to antidepressants at 6 months with the different types of interventions (OR 1.33; 95% CI: 1.09 to 1.62). The improvement in adherence is obtained from 3 months (OR 1.62, 95% CI: 1.25 to 2.10) but it is attenuated at 12 months (OR 1.25, 95% CI: 1.02 to 1.53). Selected articles show methodological differences, mainly the diversity of both the severity of the depressive disorder and intervention procedures. In the samples of these studies, patients with depression and anxiety seem to benefit most from intervention (OR 2.77, 95% CI: 1.74 to 4.42) and collaborative care is the most effective intervention to improve adherence (OR 1.88, 95% CI: 1.40 to 2.54).

CONCLUSIONS

Our findings indicate that interventions aimed at improving adherence to medication among adults with depressive disorders are effective up to six months. However, the evidence on the effectiveness of long-term adherence is insufficient and supports the need for further research efforts.

TRIAL REGISTRATION

International Prospective Register for Systematic Reviews (PROSPERO) number: CRD42017065723 .

Initial adherence by psychiatric outpatients in a general hospital and relevant personal factors

BACKGROUND

Initial adherence is a predictor of long-term adherence and thus is a crucial metric to explore and support. This study aimed to investigate initial adherence by psychiatric outpatients and relevant personal factors.

METHODS

The study surveyed psychiatric outpatients using a 30-day timely return visit rate (TRVR) after the first visit to indicate initial adherence. All participants agreed to engage in the self-designed survey and assessments of the Eysenck Personality Questionnaire (EPQ) and Symptoms Checklist-90 (SCL-90). Clients who missed timely return visits received telephone follow-up to determine the main reasons.

RESULTS

The overall TRVR was 59.4, and 40.6% of clients missed return visits. Logistic regression analysis revealed risk factors for initial adherence were work, tense family atmosphere, negative attitudes towards medication, higher EPQ psychoticism score, and lower SCL-90 phobic anxiety score. The main reasons given for non-timely return visits were improvement suggesting lack of need for a return visit, various barriers, no improvement, and side effects.

CONCLUSION

Psychiatric outpatients had poor initial adherence related to multiple dimensional factors, including job, family, personality characteristics, mental status, and thoughts about mental illness and treatments.

Interventions to Improve Medication Adherence in People with Schizophrenia: A Systematic Review

Nonadherence to medications is very common in people with schizophrenia. Numerous methods have been implemented to improve medication adherence. The study aimed to determine what interventions have been used and to assess the effectiveness of these in improving medication adherence in people with schizophrenia. Two electronic databases (PubMed and Science Direct) and a manual search were used to locate RCT studies that examined interventions in medication adherence for schizophrenia, published between 2011 and 2022. The search was conducted using the terms (schizophrenia OR schizophrenic) AND (interventions OR adherence therapy) AND (medication adherence OR medication compliance). Sixteen studies were included, and relevant data were extracted and selected. Sixteen studies used interventions that involve family, health professionals (psychiatrists, psychologists, nurses, and pharmacists), SMS, and smart electronic reminders. Medication adherence was measured using medication refill records from hospital dispensing records or claim databases, electronic devices, plasma blood concentration, and participant self-reporting. Thirteen out of 15 studies showed significant improvements in adherence compared to routine care. The other three studies did not result in improved medication adherence. Interventions with diverse strategies delivered to individuals with schizophrenia showed the potential to reduce medication non-adherence in people with schizophrenia so that they can be utilized as an alternative to support treatment in people with schizophrenia in addition to antipsychotic medication. In future research strategies, it will be necessary to identify the main problems regarding nonadherence in people with schizophrenia individually and also identify the patient's perception of medication, illness, and behavior when taking medication in order to determine the next intervention that will be appropriate based on the patient's needs to improve adherence.