Attitudes regarding the collaborative practice model and treatment adherence among individuals with bipolar disorder

Problem-Oriented Integrative Therapy: Maximizing Clinical Flexibility in Treating Complex Psychiatric Conditions

Although integrative therapies are increasingly popular in clinical psychology, their dissemination in the psychiatric literature has been limited. To care for patients living with complex psychiatric problems, the authors formulated a flexible, pragmatic, problem-oriented integrative therapy (PIT). The aims of this article are to increase psychiatric attention to the value of integrative therapies, authorize their use, and present the authors' PIT approach. PIT combines common factors, theoretical synthesis, and technical eclecticism. After delineating patients' problems and goals, clinicians apply discrete therapeutic elements derived by unbundling numerous theories and practices. Clinicians improvise and pivot their practice in response to patients' shifting problems and goals, as well as to advances in the field. Practicing PIT requires familiarity with numerous therapeutic theories and models and a willingness to continually expand skill sets. PIT's effectiveness may be assessed by comparing results obtained with PIT with those obtained via conventional psychotherapeutic modalities.

Consumer involvement and guiding frameworks in mental healthcare: An integrative literature review

Perspectives of healthcare have, in past decades, focused more on active citizenship, human rights and empowerment. Healthcare consumer involvement as a concept is still unstructured and consumers have no apparent opportunities to participate in their care processes. The focus is often on the expertise of professionals, even if mental health consumers are willing to become involved and have sufficient decisional capacity. The aim of this integrative literature review was to construct an understanding of consumer perceptions and guiding frameworks of consumer involvement. There was no previous synthesis of mental health consumer perceptions combined with guiding frameworks. An integrative review methodology was employed, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The quality of the 18 studies included was analysed with the Whittemore and Knafl approach. By following Braun and Clarke's guidelines, an inductive thematic analysis was conducted to collate the themes from the selected papers. Mental health consumers' perceptions of involvement included expectations of person-centred care, such as respect, dignity, equal interaction, supportive environments and being part of a community. This research did not find any single established framework to give clear guidelines for consumer involvement in mental healthcare, but similar determinants describing various frameworks were uncovered. This review also shows how the terminology has changed throughout the years. The perceptions of mental health consumers need to be considered to enable the implementation of person-centredness from guidelines through to practice. Paying more attention to the education of professional mental health caregivers and the involvement of mental health consumers in their care provides better opportunities to co-develop successful mental health services and recovery processes.

Collaborative care approaches for people with severe mental illness

BACKGROUND

Collaborative care for severe mental illness (SMI) is a community-based intervention that promotes interdisciplinary working across primary and secondary care. Collaborative care interventions aim to improve the physical and/or mental health care of individuals with SMI. This is an update of a 2013 Cochrane review, based on new searches of the literature, which includes an additional seven studies.

OBJECTIVES

To assess the effectiveness of collaborative care approaches in comparison with standard care (or other non-collaborative care interventions) for people with diagnoses of SMI who are living in the community.

SEARCH METHODS

We searched the Cochrane Schizophrenia Study-Based Register of Trials (10 February 2021). We searched the Cochrane Common Mental Disorders (CCMD) controlled trials register (all available years to 6 June 2016). Subsequent searches on Ovid MEDLINE, Embase and PsycINFO together with the Cochrane Central Register of Controlled Trials (with an overlap) were run on 17 December 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) where interventions described as 'collaborative care' were compared with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI. SMI was defined as schizophrenia, other types of schizophrenia-like psychosis or bipolar affective disorder. The primary outcomes of interest were: quality of life, mental state and psychiatric admissions at 12 months follow-up.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently extracted data. We assessed the quality and certainty of the evidence using RoB 2 (for the primary outcomes) and GRADE. We compared treatment effects between collaborative care and standard care. We divided outcomes into short-term (up to six months), medium-term (seven to 12 months) and long-term (over 12 months). For dichotomous data we calculated the risk ratio (RR) and for continuous data we calculated the standardised mean difference (SMD), with 95% confidence intervals (CIs). We used random-effects meta-analyses due to substantial levels of heterogeneity across trials. We created a summary of findings table using GRADEpro.

MAIN RESULTS

Eight RCTs (1165 participants) are included in this review. Two met the criteria for type A collaborative care (intervention comprised of the four core components). The remaining six met the criteria for type B (described as collaborative care by the trialists, but not comprised of the four core components). The composition and purpose of the interventions varied across studies. For most outcomes there was low- or very low-certainty evidence. We found three studies that assessed the quality of life of participants at 12 months. Quality of life was measured using the SF-12 and the WHOQOL-BREF and the mean endpoint mental health component scores were reported at 12 months. Very low-certainty evidence did not show a difference in quality of life (mental health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.03, 95% CI -0.26 to 0.32; 3 RCTs, 227 participants). Very low-certainty evidence did not show a difference in quality of life (physical health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.08, 95% CI -0.18 to 0.33; 3 RCTs, 237 participants). Furthermore, in the medium term (at 12 months) low-certainty evidence did not show a difference between collaborative care and standard care in mental state (binary) (RR 0.99, 95% CI 0.77 to 1.28; 1 RCT, 253 participants) or in the risk of being admitted to a psychiatric hospital at 12 months (RR 5.15, 95% CI 0.67 to 39.57; 1 RCT, 253 participants). One study indicated an improvement in disability (proxy for social functioning) at 12 months in the collaborative care arm compared to usual care (RR 1.38, 95% CI 0.97 to 1.95; 1 RCT, 253 participants); we deemed this low-certainty evidence. Personal recovery and satisfaction/experience of care outcomes were not reported in any of the included studies. The data from one study indicated that the collaborative care treatment was more expensive than standard care (mean difference (MD) international dollars (Int$) 493.00, 95% CI 345.41 to 640.59) in the short term. Another study found the collaborative care intervention to be slightly less expensive at three years.

AUTHORS' CONCLUSIONS

This review does not provide evidence to indicate that collaborative care is more effective than standard care in the medium term (at 12 months) in relation to our primary outcomes (quality of life, mental state and psychiatric admissions). The evidence would be improved by better reporting, higher-quality RCTs and the assessment of underlying mechanisms of collaborative care. We advise caution in utilising the information in this review to assess the effectiveness of collaborative care.

Experiences that matter in bipolar disorder: a qualitative study using the capability, comfort and calm framework

BACKGROUND

When assessing the value of an intervention in bipolar disorder, researchers and clinicians often focus on metrics that quantify improvements to core diagnostic symptoms (e.g., mania). Providers often overlook or misunderstand the impact of treatment on life quality and function. We wanted to better characterize the shared experiences and obstacles of bipolar disorder within the United States from the patient's perspective.

METHODS

We recruited 24 individuals diagnosed with bipolar disorder and six caretakers supporting someone with the condition. Participants were involved in treatment or support services for bipolar disorder in central Texas. As part of this qualitative study, participants discussed their everyday successes and obstacles related to living with bipolar disorder during personalized, open-ended interviews. Audio files were transcribed, and Nvivo software processed an initial thematic analysis. We then categorized themes into bipolar disorder-related obstacles that limit the patient's capability (i.e., function), comfort (i.e., relief from suffering) and calm (i.e., life disruption) (Liu et al., FebClin Orthop 475:315-317, 2017; Teisberg et al., MayAcad Med 95:682-685, 2020). We then discuss themes and suggest practical strategies that might improve the value of care for patients and their families.

RESULTS

Issues regarding capability included the struggle to maintain identity, disruptions to meaningful employment, relationship loss and the unpredictable nature of bipolar disorder. Comfort related themes included the personal perception of diagnosis, social stigma and medication issues. Calm themes included managing dismissive doctors, finding the right psychotherapist and navigating financial burdens.

CONCLUSIONS

Qualitative data from patients with bipolar disorder helps identify gaps in care or practical limitations to treatment. When we listen to these individuals, it is clear that treatments must also address the unmet psychosocial impacts of the condition to improve patient care, capability and calm.

Evaluation of factors associated with medication adherence in patients with bipolar disorder using a medication event monitoring system: a 6-month follow-up prospective study

BACKGROUND

Non-adherence in patients with bipolar disorder (BD) results in symptoms, such as aggravation, BD recurrence, emergency room visits, re-hospitalization, and poor psychosocial outcomes. Though non-adherence rates have been reported to range between 30-50% in patients with BD, the problem of adherence is often either overlooked by the physician or denied by the patient. An essential first step to enhancing medication adherence is to objectively estimate adherence. The Medication Event Monitoring System (MEMS), which is a pill bottle cap with a microprocessor, is an accurate device for assessing medication adherence. Using the MEMS, we aimed to measure medication adherence in patients with BD and evaluate the factors associated with and 6-month changes in medication adherence.

METHODS

Participants with BD were recruited from the psychiatric outpatient clinic of the Korea University Guro Hospital. The medication adherence of each participant was assessed using the MEMS, a self-report, pill count, and clinician rating. MEMS-measured adherence was reassessed after 6 months. Patient demographics were recorded and clinical assessments were conducted. Data were analyzed using Kappa statistics and Pearson's correlation analysis.

RESULTS

Of the 59 participants, 50 records were included in the analysis. Patient adherence and adherence rate assessed by the MEMS were lower than those assessed by the other measures. MEMS-measured adherence was correlated more closely with pill counts than with self-reports or clinician ratings. MEMS-measured adherence was negatively associated with prescription duration and the Brief Psychiatric Rating Scale-Affect Subscale Score. Six-month changes in MEMS-measured adherence were positively associated with attitude toward drugs and negatively associated with weight gain assessed by the Udvalg for Kliniske Undersøgelser Side Effect Rating Scale.

CONCLUSIONS

Clinicians may have to consider the limited accuracy of self-reporting and clinician rating methods and exercise caution when assessing the medication adherence of patients with BD using these methods. Our findings may assist clinicians in the assessment and improvement of medication adherence in patients with BD and, consequently, may be useful for the treatment and prevention of BD recurrence.

A randomized controlled trial of customized adherence enhancement (CAE-E): study protocol for a hybrid effectiveness-implementation project

BACKGROUND

Mood-stabilizing medications are a cornerstone of treatment for people with bipolar disorder, though approximately half of these individuals are poorly adherent with their medication, leading to negative and even severe health consequences. While a variety of approaches can lead to some improvement in medication adherence, there is no single approach that has superior adherence enhancement and limited data on how these approaches can be implemented in clinical settings. Existing data have shown an increasing need for virtual delivery of care and interactive telemedicine interventions may be effective in improving adherence to long-term medication.

METHODS

Customized adherence enhancement (CAE) is a brief, practical bipolar-specific approach that identifies and targets individual patient adherence barriers for intervention using a flexibly administered modular format that can be delivered via telehealth communications. CAE is comprised of up to four standard treatment modules including Psychoeducation, Communication with Providers, Medication Routines, and Modified Motivational Interviewing. Participants will attend assigned module sessions with an interventionist based on their reasons for non-adherence and will be assessed for adherence, functioning, bipolar symptoms, and health resource use across a 12-month period. Qualitative and quantitative data will also be collected to assess barriers and facilitators to CAE implementation and reach and adoption of CAE among clinicians in the community.

DISCUSSION

The proposed study addresses the need for practical adherence interventions that are effective, flexible, and designed to adapt to different settings and patients. By focusing on a high-risk, vulnerable group of people with bipolar disorder, and refining an evidence-based approach that will integrate into workflow of public-sector care and community mental health clinics, there is substantial potential for improving bipolar medication adherence and overall health outcomes on a broad level.

TRIAL REGISTRATION

The study was registered on ClinicalTrials.gov NCT04622150 on November 9, 2020.

Composition of treatment alliance in bipolar disorder: A cross-sectional study of patients’ perspectives

BACKGROUND

Treatment alliance has an impact on several key patient outcomes in all psychiatric disorders, including bipolar disorder (BD). It has been suggested that the construct of treatment alliance is different among patients from routine psychiatric settings compared to psychotherapeutic settings. However, research on the composition of treatment alliance in psychiatric disorders, such as BD, is relatively limited.

AIM

To determine whether a broader construct of treatment alliance was prevalent among outpatients with BD.

METHODS

This is a cross-sectional study, conducted in the psychiatric unit of a multi-specialty hospital in north India over 12 mo (September 2018 to September 2019). A consecutive sample of 160 remitted adult outpatients with BD on mood stabilizers for at least a year were selected. The principal instrument to assess treatment alliance was the Working Alliance Inventory-client version (WAI-Client). Other potential constituents of the alliance explored were perceived trust in clinicians assessed by the Trust in Physicians (TRIP) scale, perceived support from clinicians assessed by the Psychosocial Care by Physicians (PCP) scale, and perceived treatment satisfaction assessed by the Patient Satisfaction Questionnaire (PSQ). Associations between scores on all scales were determined by correlational and multiple regression analyses. Exploratory factor analysis of combined items of all scales was conducted using a principal components analysis.

RESULTS

Scores on all the three WAI-Client subscales were significantly correlated with each other (r = 0.66-0.81; P < 0.0001). The total TRIP scores were associated with the total WAI-Client scores (r = 0.28; P < 0.01). The total TRIP scores and the total PCP scores were also significantly associated with the WAI-Client scores on the Task subscale (r = 0.28-0.29; P < 0.01). The total TRIP scores were significantly associated with the total PSQ scores (r = 0.45; P < 0.0001). Factor analysis yielded two independent and coherent factors, which explained 69% of the variance in data. Factor-1 (“alliance and support”), which explained about 41% of the variance, was comprised of a combined WAI-Client goal-task-bond component as well as the PCP support items. Factor-2 (“trust and satisfaction”), which explained about 28% of the variance, consisted of all the TRIP trust and the PSQ treatment satisfaction items.

CONCLUSION

A broader construct of treatment alliance in BD was found. Apart from collaborative components, this construct included patients’ perceptions regarding trust in clinicians, support from clinicians, and treatment satisfaction.

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.

How Knowledge Mapping Can Bridge the Communication Gap Between Caregivers and Health Professionals Supporting Individuals With Complex Medical Needs: A Study in Fragile X Syndrome

The challenges of caring for children with complex health needs, such as intellectual disability (ID) and autism spectrum disorder (ASD), are multiple and experienced by both caregivers and health professionals. Fragile X syndrome (FXS) is the most common single gene cause of ID and ASD, and provides a pertinent model to understand these complexities of care, as well as the communication challenges experienced between caregivers and healthcare professionals. In recent years both caregivers and healthcare professionals have recognized the need for enhancing communication both in clinical and research settings. Knowledge mapping has emerged as a tool to support quality communication between team participants. Here we review how differences in mental models, as well as challenges related to health literacy and knowledge transfer can have an impact on communication. Next, we present different knowledge mapping approaches used in complex situations, with a focus on concept maps and care maps. Finally, we highlight the potential benefits and limitations of mapping to improve communication issues related to caring for individuals with FXS and potentially other neurodevelopmental disorders (NDDs).

Relapse prevention in ambulant mental health care tailored to patients with schizophrenia or bipolar disorder

WHAT IS ALREADY KNOWN ON THE SUBJECT?: Understanding the need for psychoeducation and management strategies in relapse prevention, for individuals with schizophrenia or bipolar disorder. Interventions for individuals with severe mental illness, especially schizophrenia, often requires support from family or social network to successfully improve mental stability in the life of the mentally ill. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: To our knowledge, no previous review has provided an overview of state of the art intervention elements currently used in ambulant mental health care interventions and how these elements are combined in interventions tailored to individuals with schizophrenia or bipolar disorder. Moreover, this systematic review indicates the effect of the different intervention elements. This review reveals an apparent gab in knowledge regarding patient perceptions of and need for individualized relapse prevention interventions. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The review is a relevant tool for stakeholders and practitioners in community mental health service when planning future interventions. Considering the specific needs for intervention complexity of the target group is likely to improve not only treatment outcome, but also patient satisfaction and treatment adherence. ABSTRACT: Introduction In recent years, there has been a development in ambulant mental health care towards a more preventive approach, resulting in relapse prevention interventions. Interventions may be patient tailored, to a greater or lesser extent, in relation to the treatment elements included. Aim To create an overview of non-pharmacological intervention elements described in relapse prevention interventions for patients with schizophrenia or bipolar disorder based on a systematic review. Method Six scientific databases were systematically searched. The search strategy, identification and selection of literature complied with the PRISMA statement. Results Of 7.429 studies screened, 25 were included for analysis. Six treatment elements were identified: Pharmacological treatment, personalized action plan, patient education, patient skills, treatment adherence and family involvement. Discussion The varying degree of complexity of the interventions indicates that patients with bipolar disorder and schizophrenia have, respectively, different treatment needs. Patients with schizophrenia seem to benefit more from interventions that include support from social network or family than patients with bipolar disorder. More qualitative studies clarifying the patient's perspective on tailored relapse prevention are indicated. Implications for practice Optimally tailoring relapse prevention for patients with schizophrenia and bipolar disorder will improve treatment outcome, and probably also treatment satisfaction and adherence.

Development of Coaching Support for LiveWell: A Smartphone-Based Self-Management Intervention for Bipolar Disorder

Despite effective pharmacological treatment, bipolar disorder is a leading cause of disability due to recurrence of episodes, long episode durations, and persistence of interepisode symptoms. While adding psychotherapy to pharmacotherapy improves outcomes, the availability of adjunctive psychotherapy is limited. To extend the accessibility and functionality of psychotherapy for bipolar disorder, we developed LiveWell, a smartphone-based self-management intervention. Unfortunately, many mental health technology interventions suffer from high attrition rates, with users rapidly failing to maintain engagement with the intervention technology. Human support reduces this commonly observed engagement problem but does not consistently improve clinical and recovery outcomes. To facilitate ongoing efforts to develop human support for digital mental health technologies, this paper describes the design decisions, theoretical framework, content, mode, timing of delivery, and the training and supervision for coaching support of the LiveWell technology. This support includes clearly defined and structured roles that aim to encourage the use of the technology, self-management strategies, and communication with care providers. A clear division of labor is established between the coaching support roles and the intervention technology to allow lay personnel to serve as coaches and thereby maximize accessibility to the LiveWell intervention.

Psychological factors involved in psychopharmacological medication adherence in mental health patients: A systematic review

BACKGROUND

Psychopharmacological medication adherence is essential for psychiatric patients' treatment and well-being.

OBJECTIVE

This review aimed to identify psychological factors related to health control that have been linked to psychopharmacological medication adherence in psychiatric patients.

METHODS

A literature search was performed through the databases Medline, PubMed, PsycINFO, and Google Scholar to identify relevant studies published before October 15th, 2019. Articles published in peer-reviewed journals that analyzed the psychological factors of health belief and health control involved in psychopharmacological medication adherence in a psychiatric population were included.

RESULTS

The search identified 124 potentially relevant papers, 29 of which met the eligibility criteria. The final sample was 222 adolescents, most with a diagnosis of attention deficit/hyperactivity disorder (ADHD), and 6139 adults diagnosed especially with schizophrenia spectrum disorder, bipolar disorder, or depressive disorder. Results suggested that medication adherence is associated with health beliefs and psychological variables, such as self-efficacy and locus of control. Family support was also positively related to medication adherence.

CONCLUSION

Psychopharmacological medication adherence requires a consideration of multicausality, which depends on sociodemographic, clinical, and psychological factors.

PRACTICE IMPLICATIONS

These findings should be considered in the development and implementation of psychological interventions focused on self-control and family support.

Treatment Attitudes and Adherence Among Patients with Bipolar Disorder: A Systematic Review of Quantitative and Qualitative Studies

BACKGROUND

Systematic reviews about treatment attitudes of patients influencing adherence in bipolar disorder (BD) are rare.

METHODS

A systematic review was conducted according to the PRISMA guidelines and principles of thematic synthesis. Selectively identified quantitative and qualitative studies were used to examine the attitude-adherence relationship in BD, the types and correlates of treatment attitudes, and the impact of psychosocial interventions on attitudes.

RESULTS

The final list of 163 articles included 114 observational reports (incorporating 21 psychosocial intervention trials), 45 qualitative/descriptive studies, and 4 patient surveys. A positive association between treatment attitudes and adherence was found in most quantitative and qualitative studies, though the strength of the relationship was unclear. Thematic analysis of qualitative studies suggested that patient attitudes influencing adherence were based on perceived advantages and disadvantages of treatment. The principal correlates of patients' attitudes were family attitudes, the clinician-patient alliance, social support, and patients' knowledge of BD. Though negative attitudes such as denial, concerns about adverse treatment consequences, and stigmatizing effects of treatment were common, many patients believed treatment to be beneficial and necessary. The limited data on the effect of psychosocial interventions indicated that treatments selectively targeting attitudes enhanced adherence.

LIMITATIONS

The studies were heterogeneous in design; the quality was uneven (fair to poor); and the risk of bias moderate to high.

CONCLUSIONS

Despite these flaws, awareness of the existing evidence on the attitude-adherence association and other aspects of treatment attitudes in BD can help in efforts to address nonadherence in BD.

Phase II Randomised Controlled Trial of a patient decision-aid website to improve treatment decision-making for young adults with bipolar II disorder: A feasibility study protocol

BACKGROUND/AIMS

This paper describes the protocol for a feasibility study for a parallel Phase II randomised control trial (RCT) aiming to evaluate a novel decision-aid website (e-DA) to support young adults with bipolar II disorder (BPII), and their families.

MATERIAL AND METHODS

The e-DA was developed according to the International Patient Decision-Aid Standards (IPDAS). Participants will be 40 young adults (18-30 years) referred to a specialist outpatient clinical facility, who have a confirmed clinical diagnosis of BPII. Participants will be randomised (1:1) to receive access to the clinic's online factsheets/website with (Intervention) or without (Control) the e-DA. A series of validated and purpose-designed questionnaires will be administered at baseline (T0), immediately post-decision (T1), and 3 months post-decision (T2). Questionnaires assess key decision-making constructs related to decision-making quality, including: decisional conflict, subjective and objective treatment knowledge, values-based informed choice, concordance between preferred/actual decision-making involvement, preparation for decision-making, and decisional regret. Self-report symptom severity and anxiety will ascertain the safety of e-DA use. The focus of analyses will be to assess effect sizes, in order to guide a future RCT.

DISCUSSION

This feasibility study will evaluate a world first, evidence-based online decision-support resource, a DA website, for young adults with BPII and their families who are deciding on treatment options for relapse prevention. Findings will determine the e-DA's feasibility in RCT procedures (i.e., outpatient clinical setting) and provide estimates of effect sizes on outcomes related to improving treatment decision-making and patient outcomes in a sample of potential end-users, compared to usual care.

TRIAL REGISTRATION

This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12617000840381.

Treatment alliance and adherence in bipolar disorder

The clinician patient relationship lies at the core of psychiatric practice and delivery of mental health care services. The concept of treatment alliance in psychiatry has its origins in psychotherapy, but has also been influenced by several other constructs such as patient-centred care (PCC) and shared decision-making (SDM). Similarly, there has been a shift in conceptualization of treatment-adherence in psychiatric disorders including bipolar disorder (BD) from illness-centred and clinician-centred approaches to patient-centred ones. Moreover, the traditional compliance based models are being replaced by those based on concordance between clinicians and patients. Newer theories of adherence in BD place considerable emphasis on patient related factors and the clinician patient alliance is considered to be one of the principal determinants of treatment-adherence in BD. Likewise, current notions of treatment alliance in BD also stress the importance of equal and collaborative relationships, sensitivity to patients' viewpoints, sharing of knowledge, and mutual responsibility and agreement regarding decisions related to treatment. Accumulated evidence from quantitative research, descriptive accounts, qualitative studies and trials of psychosocial interventions indicates that efficacious treatment alliances have a positive influence on adherence in BD. Then again, research on the alliance-adherence link in BD lags behind the existing literature on the subject in other medical and psychiatric conditions in terms of the size and quality of the evidence, the consistency of its findings and clarity about underlying processes mediating this link. Nevertheless, the elements of an effective alliance which could have a positive impact on adherence in BD are reasonably clear and include PCC, collaborative relationships, SDM, open communication, trust, support, and stability and continuity of the relationship. Therefore, clinicians involved in the care of BD would do well to follow these principles and improve their interpersonal and communication skills in order to build productive alliances with their patients. This could go a long way in confronting the ubiquitous problem of non-adherence in BD. The role of future research in firmly establishing the alliance-adherence connection and uncovering the processes underlying this association will also be vital in devising effective ways to manage non-adherence in BD.

Shared decision making in pharmacotherapy decisions, perceived by patients with bipolar disorder

Background

Shared decision making has been promoted as standard care, but there has been debate on the possible types. On the one hand, there is a more ‘instrumental’/objective approach focused on the exchange of information, but an ‘interpersonal’/subjective patient involvement has been suggested as well. In this study we aim to investigate this further by assessing both actual and perceived patient involvement in medical decisions.

Methods

Eighty-one consultations between patients with bipolar disorder and their clinicians were observed and scored using the OPTION scale. Afterwards, the patients’ experienced involvement was explored with the SDM-Q-9. Furthermore, several patient characteristics were gathered. Correlations between the scores were examined.

Results

The clinicians scored on average 34.6 points on the OPTION scale. In contrast, patients scored on average 77.5 points on the SDM-Q-9, suggesting that patients felt more involved in the consultation than was observable.

Conclusion

Our patients with bipolar disorder feel involved in pharmacotherapy decisions, but this is not scored in objective observations. Our data suggest that there are implicit, interpersonal aspects of patient involvement in shared decision making, a concept that deserves further attention and conceptualisation.

Psychoeducation for bipolar disorder: A discourse analysis

Psychoeducation has become a common intervention within mental health settings. It aims to increase people's ability to manage a life with a long-term illness. For people with bipolar disorder, psychoeducation is one of a range of psychosocial interventions now considered part of contemporary mental health practice. It has taken on a 'common sense' status that results in little critique of psychoeducation practices. Using a published manual on psychoeducation and bipolar disorder as its data, Foucauldian discourse analysis was used in the present study for a critical perspective on psychoeducation in order to explore the taken-for-granted assumptions on which it is based. It identifies that the text produces three key subject positions for people with bipolar disorder. To practice self-management, a person must: (i) accept and recognize the authority of psychiatry to know them; (ii) come to see that they can moderate themselves; and (iii) see themselves as able to undertake a reflexive process of self-examination and change. These findings highlight the circular and discursive quality to the construct of insight that is central to how psychoeducation is practiced. Using Foucault's construct of pastoral power, it also draws attention to the asymmetrical nature of power relations between the clinician and the person with bipolar disorder. An effect of the use of medical discourse in psychoeducation is to limit its ability to work with ambivalence and contradiction. A critical approach to psychotherapy and education offers an alternate paradigm on which to basis psychoeducation practices.

Qualitative systematic review of barriers and facilitators to patient-involved antipsychotic prescribing

BACKGROUND

Despite policy and practice mandates for patient involvement, people with serious mental illness often feel marginalised in decisions about antipsychotic medication. Aims To examine stakeholder perspectives of barriers and facilitators to involving people with serious mental illness in antipsychotic prescribing decisions.

METHOD

Systematic thematic synthesis.

RESULTS

Synthesis of 29 studies identified the following key influences on involvement: patient's capability, desire and expectation for involvement, organisational context, and the consultation setting and processes.

CONCLUSIONS

Optimal patient involvement in antipsychotic decisions demands that individual and contextual barriers are addressed. There was divergence in perceived barriers to involvement identified by patients and prescribers. For example, patients felt that lack of time in consultations was a barrier to involvement, something seldom raised by prescribers, who identified organisational barriers. Patients must understand their rights to involvement and the value of their expertise. Organisational initiatives should mandate prescriber responsibility to overcome barriers to involvement. Declaration of interest None.

A Qualitative Exploration of Clinician Views and Experiences of Treatment Decision-Making in Bipolar II Disorder

This study qualitatively explored clinicians' views and experiences of treatment decision-making in BPII. Semi-structured interviews were conducted with 20 practising clinicians (n = 10 clinical psychologists, n = 6 GPs, n = 4 psychiatrists) with experience in treating adult outpatients with BPII. Interviews were audiotaped, transcribed verbatim and thematically analysed using framework methods. Professional experience, and preferences for patient involvement in decision-making were also assessed. Qualitative analyses yielded four inter-related themes: (1) (non-)acceptance of diagnosis and treatment; (2) types of decisions; (3) treatment uncertainty and balancing act; and (4) decision-making in consultations. Clinician preferences for treatment, professional experience, and self-reported preferences for patient/family involvement seemed to influence decision-making. This study is the first to explore clinician views and experiences of treatment decision-making in BPII. Findings demonstrate how clinician-related factors may shape treatment decision-making, and suggest potential problems such as patient perceptions of lower-than-preferred involvement.

Treatment-adherence in bipolar disorder: A patient-centred approach

About half of the patients diagnosed with bipolar disorder (BD) become non-adherent during long-term treatment, a rate largely similar to other chronic illnesses and one that has remained unchanged over the years. Non-adherence in BD is a complex phenomenon determined by a multitude of influences. However, there is considerable uncertainty about the key determinants of non-adherence in BD. Initial research on non-adherence in BD mostly limited itself to examining demographic, clinical and medication-related factors impacting adherence. However, because of inconsistent results and failure of these studies to address the complexities of adherence behaviour, demographic and illness-related factors were alone unable to explain or predict non-adherence in BD. This prompted a shift to a more patient-centred approach of viewing non-adherence. The central element of this approach includes an emphasis on patients’ decisions regarding their own treatment based on their personal beliefs, life circumstances and their perceptions of benefits and disadvantages of treatment. Patients’ decision-making processes are influenced by the nature of their relationship with clinicians and the health-care system and by people in their immediate environment. The primacy of the patient’s perspective on non-adherence is in keeping with the current theoretical models and concordance-based approaches to adherence behaviour in BD. Research over the past two decades has further endorsed the critical role of patients’ attitudes and beliefs regarding medications, the importance of a collaborative treatment-alliance, the influence of the family, and the significance of other patient-related factors such as knowledge, stigma, patient satisfaction and access to treatment in determining non-adherence in BD. Though simply moving from an illness-centred to a patient-centred approach is unlikely to solve the problem of non-adherence in BD, such an approach is more likely to lead to a better understanding of non-adherence and more likely to yield effective solutions to tackle this common and distressing problem afflicting patients with BD.

Communication and decision-making in mental health: A systematic review focusing on Bipolar disorder

OBJECTIVES

To systematically review studies of communication and decision-making in mental health-based samples including BP patients.

METHODS

Qualitative systematic review of studies using PsychINFO, MEDLINE, SCOPUS, CINAHL, and EMBASE (January 2000-March 2015). One author assessed study eligibility, verified by two co-authors. Data were independently extracted by two authors, and cross-checked by another co-author. Two independent raters assessed eligible studies using a validated quality appraisal.

RESULTS

Of 519 articles retrieved, 13 studies were included (i.e., 10 quantitative/1 qualitative/1 mixed-methods). All were cross-sectional; twelve were rated good/strong quality (>70%). Four inter-related themes emerged: patient characteristics and patient preferences, quality of patient-clinician interactions, and influence of SDM/patient-centred approach on patient outcomes. Overall BP patients, like others, have unmet decision-making needs, and desire greater involvement. Clinician consultation behaviour influenced patient involvement; interpersonal aspects (e.g., empathy, listening well) fostered therapeutic relationships and positive patient outcomes, including: improved treatment adherence, patient satisfaction with care, and reduced suicidal ideation.

CONCLUSIONS

This review reveals a paucity of studies reporting bipolar-specific findings. To inform targeted BP interventions, greater elucidation of unmet decision-making needs is needed.

PRACTICE IMPLICATIONS

Eliciting patient preferences and developing a collaborative therapeutic alliance may be particularly important in BP, promoting improved patient outcomes.

Coping strategies used by poorly adherent patients for self-managing bipolar disorder

BACKGROUND

Bipolar disorder (BD) is a chronic mental illness associated with reduced quality of life, high rates of suicide, and high financial costs. Evidence indicates that psychosocial stress might play an important role in the onset and course of BD.

OBJECTIVE

The objective of this study was to address the gap between coping theory and the clinical use of coping strategies used to self-manage BD.

METHODS

In-depth interviews were conducted with a sample of 21 poorly adherent patients with BD. All interviews were audiotaped, transcribed verbatim, and analyzed using content analysis with an emphasis on dominant themes.

RESULTS

Transcript-based analysis generated two major domains of coping strategies used to self-manage BD: 1) problem focused (altering eating habits, managing mood-stabilizing medications, keeping psychiatric appointments, seeking knowledge, self-monitoring, and socializing) and 2) emotion focused (distracting activities, denial, isolation, modifying/avoiding, helping others, and seeking social support). Participants used both types of coping strategies to deal with stressful situations brought about by the internal and external demands associated with self-management of BD.

CONCLUSION

This qualitative study provided a first step in evaluating coping strategies as a possible mediator in the self-management of BD and has implications for health care providers. Being able to characterize an individual's coping behaviors can help patients modify or replace more maladaptive coping with better coping strategies in the self-management of this chronic mental illness.

Health promotion and disease prevention strategies for today's physicians

The majority of preventable diseases in both developed and developing countries could be strategically controlled by effectively implementing existing health promotion and disease prevention (HPDP) interventions. An important juncture for the implementation of risk-reduction strategies is the point of interaction between health care providers and patients during their scheduled visits. This article targets strategies for physicians to effectively implement HPDP interventions in a clinical setting. The factors that improve delivery of HPDP interventions are discussed briefly. We subsequently introduce and discuss the conceptual framework for enhanced patient education, which is based on the information-motivation-behavioral skills model and the health belief model. The article also describes an adapted patient-practitioner collaborative model for HPDP. This adapted model may serve as a blueprint for physicians to effectively execute HPDP interventions during clinical encounters. The recommended models and our conceptual frameworks could have limitations which need to be field tested.

Strategies to predict, measure, and improve psychosocial treatment adherence

Nonadherence to psychosocial and behavioral treatment is a significant public health problem that presents a barrier to recovery and effective treatment. An estimated 20% to 70% of individuals who initiate psychosocial mental health services discontinue treatment prior to clinicians' recommendations. Empirically supported, evidence-based, stand-alone or adjunctive psychosocial interventions treat an increasingly wide range of mental health conditions. A core assumption of most, if not all, interventions is that clients will fully and actively engage in the treatment protocol. Adherence to psychosocial treatment has received much less scientific attention, however, than adherence to medical treatment. Drawing extensively from existing research, this comprehensive review conceptualizes several types of psychosocial and behavioral treatment adherence, examines predictors of adherence to psychosocial treatment, summarizes measures of adherence, and describes existing interventions to enhance psychosocial treatment adherence.

Treatment adherence towards prescribed medications in bipolar-II acute depressed patients: relationship with cyclothymic temperament and "therapeutic sensation seeking" in response towards subjective intolerance to pain

BACKGROUND

Treatment adherence (TA) is crucial during almost any phase of bipolar disorder (BD), including type-II (BD-II) acute depression. While a number of issues have been traditionally accounted on the matter, additional factors should be likewise involved, including affective temperaments and some clinically suggestive psychopathological traits whose systematic assessment represents the aim of this study.

METHODS

Two hundred and twenty BD-II acute depressed outpatients were consecutively evaluated using the Structured Clinical Interviews for Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition Axis-I and II Disorders, Hamilton scales for Depression and Anxiety, Temperament Evaluation of the Memphis Pisa Paris San Diego-Auto-questionnaire-110-item, Visual Analogue Scale (VAS), Zuckerman's Sensation-Seeking Scale-Form-V (SSS-V), Barratt's Impulsivity Scale-11-item, State-Trait Anxiety Inventory modules, Severity module of the Clinical Global Impression Scale for BD, Morisky 8-Item Medication Adherence Scale (MMAS-8) and the Clinician Rating Scale (CRS). Patients were divided into non-adherent vs. treatment-adherent cases depending on MMAS-8+CRS scores.

RESULTS

In the TA(-) group, higher VAS and cyclothymic temperament scores were highly correlated (r=.699; p≤.001). Those latter scores, along with SSS-V scores and the occurrence of lifetime addiction to painkiller and/or homeopathic medications available over the counter defined a "therapeutic sensation seeking" pattern allowing to correctly classify as much as 93.9% [Exp(B)=3.490; p≤.001] of TA(-) cases (49/220).

LIMITS

Lack of objective TA measures and systematic pharmacological record; recall bias on some diagnoses; and relatively small sample size.

CONCLUSIONS

Stating the burden of TA in BD, additional studies on this regard are aimed, ideally contributing to enhance the management of BD itself.

Association between therapeutic alliance, care satisfaction, and pharmacological adherence in bipolar disorder

OBJECTIVES

We sought to understand the association of specific aspects of care satisfaction, such as patients' perceived relationship with their psychiatrist and access to their psychiatrist and staff, and therapeutic alliance with participants' likelihood to adhere to their medication regimens among patients with bipolar disorder.

METHODS

We examined data from the multicenter Systematic Treatment Enhancement Program for Bipolar Disorder, an effectiveness study investigating the course and treatment of bipolar disorder. We expected that participants (n = 3037) with positive perceptions of their relationship with their psychiatrist and quality of psychopharmacologic care, as assessed by the Helping Alliance Questionnaire and Care Satisfaction Questionnaire, would be associated with better medication adherence. We utilized logistic regression models controlling for already established factors associated with poor adherence.

RESULTS

Patients' perceptions of collaboration, empathy, and accessibility were significantly associated with adherence to treatment in individuals with bipolar disorder completing at least 1 assessment. Patients' perceptions of their psychiatrists' experience, as well as of their degree of discussing medication risks and benefits, were not associated with medication adherence.

CONCLUSIONS

Patients' perceived therapeutic alliance and treatment environment impact their adherence to pharmacotherapy recommendations. This study may enable psychopharmacologists' practices to be structured to maximize features associated with greater medication adherence.

A Re-View of Ambivalence in Bipolar Disorder Research

Constructed as a barrier to treatment adherence, ambivalence is typically pathologized in qualitative research on “bipolar disorder”—seen as something to be feared and eradicated. Here, I critically review this position, arguing that it is constructed through a “lens of risk” that problematically presumes people have a chronic mental illness that requires lifelong pharmaceutical intervention. I then draw on the accounts of three young women who have been diagnosed with bipolar disorder to demonstrate how people’s concerns, questions, and dreams could instead be seen as a site of expertise about diagnostic and treatment practices; in turn using their ambivalence to stitch together an alternative analytic “lens of desire” through which to re-view accounts of bipolar disorder. Overall this article is thus both a commentary on mainstream research practices in psychology and an experiment with how we might look differently; believing that perhaps the real risk associated with people’s ambivalence is its ability to force us—psychologists and psychiatrists—to question the ways in which we do madness.

Recognition as a valued human being: Perspectives of mental health service users

The acknowledgement of basic human vulnerability in relationships between mental health service users and professionals working in community-based mental health services (in Norway) was a starting point. The purpose was to explore how users of these services describe and make sense of their meetings with other people. The research is collaborative, with researcher and person with experienced-based knowledge cooperating through the research process. Data is derived from 19 interviews with 11 people who depend on mental health services for assistance at least three times a week. Data is analysed according to the Interpretative Phenomenological Analysis (IPA). Results confirm that reciprocity is fundamental for relationships, and that recognizing the individual entails personal involvement. The participants describe a struggle, and recognizing this struggle may help the professional to achieve a deeper understanding of the individual.

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.

Effectiveness of interventions to improve medication adherence in bipolar disorder

OBJECTIVE

To identify interventions that improve medication adherence in bipolar disorder.

METHOD

A review of the literature from 2004 to 2011 was conducted using Medline and manual searching.

RESULTS

Eleven studies were identified as meeting inclusion criteria. Five studies demonstrated improved medication adherence. No characteristics of the interventions, clinical characteristics of the groups or methodological factors distinguished those psychosocial interventions that demonstrated improvement from those that did not.

CONCLUSIONS

While only a few interventions improved adherence, most improved clinical outcomes. Issues were also identified about the way in which adherence is defined. It is proposed that incorporating patient preferences into measures of adherence within the context of a disorder-specific psychosocial intervention may provide an approach that demonstrates both improved adherence and improved clinical outcomes. However this requires further research.

The influence of therapeutic alliance and insight on medication adherence in schizophrenia

BACKGROUND

Poor adherence is one of the leading problems affecting the effectiveness of treatment in schizophrenia. It is an identified factor for relapse and hospitalizations with major social and economic consequences. Various determinants of poor adherence have been identified but few studies investigate the role of therapeutic alliance on medication adherence in routine mental healthcare.

AIMS

To investigate links between therapeutic alliance insight and medication adherence in routine care and community psychiatry.

METHODS

In this cross-sectional study, 38 inpatients that met ICD-10 criteria for schizophrenia or schizoaffective disorder were recruited and independently interviewed just before discharge. Various rating scales were used: the self-reported 4-Point ordinal Alliance Scale (4PAS), the Medication Adherence Rating Scale (MARS) and the Scale to assess Unawareness of Mental Disorder (SUMD). In addition, we investigated the relationships between medication adherence and clinical variables through uni- and multivariate analysis.

RESULTS

Therapeutic alliance was significantly correlated with adherence (r = 0.663, P < 0.0001) and insight (r =-0.664, P < 0.0001). Poor adherence was associated in patients with substance or alcohol use disorders (5.4 vs. 2.9, P = 0.0075, t = 2.83). No significant difference was found between the demographic characteristics of the sample, the characteristics of the treatments and adherence.

CONCLUSIONS

A weak therapeutic alliance and low insight are associated with poor adherence in patients with schizophrenia or schizoaffective disorder who were hospitalized. Specific psycho-educational programs to improve therapeutic alliance and insight should be implemented to achieve better therapeutic adherence and outcome.

Methods to limit attrition in longitudinal comparative effectiveness trials: lessons from the Lithium Treatment - Moderate dose Use Study (LiTMUS) for bipolar disorder

BACKGROUND

High attrition rates, which occur frequently in longitudinal clinical trials of interventions for bipolar disorder, limit the interpretation of results.

PURPOSE

The aim of this article is to present design approaches that limited attrition in the Lithium Treatment - Moderate dose Use Study (LiTMUS) for bipolar disorder.

METHODS

LiTMUS was a 6-month randomized, longitudinal multisite comparative effectiveness trial that enrolled bipolar participants who were at least mildly ill. Participants were randomized to either low to moderate doses of lithium or no lithium; other treatments needed for mood stabilization were administered in a guideline-informed, empirically supported, and personalized fashion to participants in both treatment arms.

RESULTS

Components of the study design that may have contributed to low attrition (16%) among 283 participants randomized included the use of (1) an intent-to-treat design, (2) a randomized adjunctive single-blind design, (3) participant reimbursement, (4) assessment of intent to attend the next study visit (included a discussion of attendance obstacles when intention was low), (5) quality care with limited participant burden, and (6) target windows for study visits.

LIMITATIONS

The relationships between attrition and effectiveness and tolerability of treatment have not been analyzed yet.

CONCLUSIONS

These components of the LiTMUS design may have limited attrition and may inform the design of future randomized comparative effectiveness trials among similar patients and those from other difficult-to-follow populations.

Medication adherence, ethnicity, and the influence of multiple psychosocial and financial barriers

Medication adherence is critical for patients with bipolar disorder to avoid symptom exacerbation and diminished quality of life. Most analyses consider adherence barriers individually rather than conjointly, while neglecting potential ethnic differences. 435 patients in the Continuous Improvement for Veterans in Care--Mood Disorders study reported multiple financial and psychosocial factors influencing adherence. Logistic regression modeled adherence as a function of perceived barriers, including cost burden, access, binge drinking, poor therapeutic alliance, and medication beliefs. Nearly half the cohort experienced adherence difficulty, averaging 2.8 barriers, with minority veterans reporting lower adherence than white patients, particularly financial burden and treatment access. Total barriers were significantly associated with worse adherence (OR = 1.24 per barrier), notably poor medication beliefs, binge drinking, and difficulty accessing psychiatric specialists (ORs of 2.41, 1.95 and 1.73, respectively). Veterans with bipolar disorder experience numerous adherence barriers, with certain obstacles proving especially pernicious. Fortunately tailored clinical interventions can improve adherence, particularly by addressing modifiable risk factors.

Methodological challenges in psychiatric treatment adherence research

Reflecting an increasing awareness of the importance of treatment adherence on outcomes in psychiatric populations, the National Institute of Mental Health (NIMH) convened a panel of treatment adherence researchers on September 27-28, 2007 to discuss and articulate potential solutions for dealing with methodological adherence research challenges. Panel discussions and presentations were augmented with targeted review of the literature on specific topics, with a focus on adherence to medication treatments in adults with serious mental illness. The group discussed three primary methodological areas: participants, measures, and interventions. When selecting patients for adherence-enhancing interventions (AEIs), a three-tier model was proposed that draws from the universal (targeting all patients receiving medication treatment for a specific condition, regardless of current adherence), selective (targeting patients at risk for nonadherence), and indicated (targeting patients who are currently nonadherent) prevention model and emphasizes careful patient characterization in relevant domains and appropriate matching of interventions to the selected population. Proposals were also made to reduce problematic selection biases in patient recruitment and retention. The panel addressed the pros and cons of various methods that can be used to measure adherence, and concluded that it is appropriate to use multiple measures whenever possible. Finally, the panel identified a broad range of intervention approaches, and conditions under which these interventions are likely to be most effective at reducing barriers to adherence and reinforcing adherence behavior.

Improving outcomes in patients with bipolar disorder through establishing an effective treatment team

A treatment gap exists between the efficacious treatments available for patients with bipolar disorder and the usual care these patients receive. This article reviews the evolution of the collaborative care treatment model, which was designed to address treatment gaps in chronic medical care, and discusses the efficacy of this model when applied to improving outcomes for patients with bipolar disorder in the primary care setting. Key elements of collaborative care include the use of evidence-based treatment guidelines, patient psychoeducation, collaborative decision-making with patients and with other physicians, and supportive technology to facilitate monitoring and follow-up of patient outcomes. Integrating psychiatric and medical health care can assist in achieving the goal of bipolar disorder treatment, which is full functional recovery for patients.

"I really don't know whether it is still there": ambivalent acceptance of a diagnosis of bipolar disorder

Questioning a diagnosis of bipolar disorder is not surprising given the chronic and fluctuating nature of the illness. Qualitative research using thematic analysis was used to derive an understanding of the process patients used to make sense of their diagnosis of bipolar disorder. The findings suggested that receiving a diagnosis was an active process. Factors such as fluctuating moods, changing diagnoses or misdiagnosis, difficulties patients have differentiating self from illness, mistrust in mental health services, and experiences of negative side effects of medication can contribute to ambivalence about the diagnosis and lead to relapse. These findings highlight the need for clinicians to focus on patients' perceptions of bipolar disorder and work with the ambivalence in the process of facilitating greater acceptance. This has the potential for reducing relapses through increased adherence with treatment.

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.

Difficult to swallow: patient preferences for alternative valproate pharmaceutical formulations

OBJECTIVE

To determine the degree to which swallowing valproate (VP) tablets is an issue, the proportion of patients who would prefer an alternative formulation, and the predictors of preference.

METHODS

A quantitative telephone survey of eligible adults (n = 400, >/=18 years old) who currently take (n = 236) or previously took (n = 164) VP tablets within the past 6 months was conducted.

RESULTS

More than half of the patients indicated that VP tablets were 'uncomfortable to swallow' (68.5%, n = 274) and were 'very interested' (65.8%, n = 263) in medications that were easier to swallow. When choosing conceptually between taking VP tablet once/day or an equally safe and effective but significantly smaller soft gel capsule twice per day, the 82.8%, (n = 331) preferred the soft gel capsule. In the multivariate regression analysis, perceiving soft gel capsules to be easier to swallow (OR = 73.54; 95% CI = 15.01 to 360.40) and taking VP more frequently (OR = 2.02; 95% CI = 1.13 to 3.61) were significant predictors of soft gel capsule treatment preference.

CONCLUSION

VP users would prefer a formulation that is easier to swallow, even if it is needed to be taken twice per day. When choosing between medications with similar efficacy and safety, physicians can consider patient preferences to optimize conditions for medication adherence.

A brief measure of perceived clinician support by patients with bipolar spectrum disorders

The quality of the patient-provider relationship is regarded as an essential ingredient in the treatment of serious mental illnesses, and is associated with favorable outcomes including improved treatment adherence. However, monitoring the strength and influence of provider support in clinical settings is challenged by the absence of brief, psychometrically sound, and easily administered assessments. The purpose of this study was to test the factor structure and examine the clinical and psychosocial correlates of a brief measure of provider support. Participants were recruited from the continuous improvement for veterans in care-Mood Disorders study (N = 429). The hypothesized factor structure exhibited a good fit with the data. At baseline, provider support was associated with higher levels of service access and medication compliance and lower levels of alcohol use and suicidality. Regular monitoring of provider support may provide useful when tailoring psychosocial treatment strategies, especially in routine care settings.

Assessment Tools for Adult Bipolar Disorder

This article reviews the current state of the literature on the assessment of bipolar disorder in adults. Research on reliable and valid measures for bipolar disorder has unfortunately lagged behind assessment research for other disorders, such as major depression. We review diagnostic tools, self-report measures to facilitate screening for bipolar diagnoses, and symptom severity measures. We briefly review other assessment domains, including measures designed to facilitate self-monitoring of symptoms. We highlight particular gaps in the field, including an absence of research on the reliable diagnosis of bipolar II and milder forms of disorder, a lack of empirical data on the best ways to integrate data from multiple domains, and a shortage of measures targeting a broader set of illness-related constructs relevant to bipolar disorder.

Enhanced relapse prevention for bipolar disorder: a qualitative investigation of value perceived for service users and care coordinators

BACKGROUND

Enhanced relapse prevention (ERP) is a psychological intervention delivered by mental health professionals to help individuals with bipolar disorder (BD) recognise and manage early warning signs for mania and depression. ERP has an emerging evidence base and is recommended as good practice for mental health professionals. However, without highly perceived value to both those receiving (services users) or delivering it (health professionals), implementation will not occur. The aim of this study is to determine what values of ERP are perceived by service users (SUs) and mental health professionals (care coordinators, CCs) providing community case management.

METHODS

A nested qualitative study design was employed as part of a randomised controlled trial of ERP. Semi-structured interviews were conducted with a purposive sub-sample of 21 CCs and 21 SUs, and an iterative approach used to develop a framework of conceptual categories that was applied systematically to the data.

RESULTS

The process of implementing and receiving ERP was valued by both SUs and CCs for three similar sets of reasons: improved understanding of BD (where a knowledge deficit of BD was perceived), enhanced working relationships, and improved ways of managing the condition. There were some differences in the implications these had for both CCs and SUs who also held some reservations.

CONCLUSION

CCs and SUs perceive similar value in early warning signs interventions to prevent relapse, and these have particular benefits to them. If this perceived value is maintained, CCs and SUs in routine practice may use ERP long-term.

Psychotropic medication nonadherence among United States Latinos: a comprehensive literature review

OBJECTIVE

Psychotropic medication nonadherence is a major public health problem, but few studies have focused on Latinos. The authors systematically reviewed the literature on rates of and factors influencing antipsychotic, antidepressant, and mood stabilizer nonadherence among U.S. Latinos.

METHODS

MEDLINE and PsycINFO were searched by using the keywords adherence, compliance, Latino, Hispanic, psychotropic, and related terms; bibliographies from relevant reviews and studies were also searched. Twenty-one studies met inclusion criteria: published since 1980 in English or Spanish and measured psychotropic medication nonadherence rates among U.S. Latino adults. Information was extracted about study design and objective, location, population, medication type, participant demographic characteristics, adherence measures, adherence rates, and factors related to adherence.

RESULTS

In the 17 studies that included Latinos and other minority groups, mean nonadherence rates were 41%, 31%, and 43%, respectively, among Latinos, Euro-Americans, and African Americans, with an overall effect size of .64 between Latinos and Euro-Americans. In the four studies that included only Latinos, the mean nonadherence rate was 44%. Ten of 16 studies found that Latinos had significantly lower adherence rates than Euro-Americans. Risk factors for nonadherence included being a monolingual Spanish speaker, lacking health insurance, experiencing access barriers to high-quality care, and having lower socioeconomic status. Protective factors included family support and psychotherapy.

CONCLUSIONS

Rates of nonadherence to psychotropic medications were found to be higher for Latinos than for Euro-Americans. Further investigation is needed to understand the potentially modifiable individual and society-level mechanisms of this discrepancy. Clinical and research interventions to improve adherence should be culturally appropriate and incorporate identified factors.

Perceived access to general medical and psychiatric care among veterans with bipolar disorder

OBJECTIVES

We examined associations between patient characteristics and self-reported difficulties in accessing mental health and general medical care services.

METHODS

Patients were recruited from the Continuous Improvement for Veterans in Care-Mood Disorders study. We used multivariable logistic regression analyses to assess whether predisposing (demographic characteristics), enabling (e.g., homelessness), or need (bipolar symptoms, substance abuse) factors were associated with difficulties in obtaining care, difficulties in locating specialty providers, and forgoing care because of cost.

RESULTS

Patients reported greater difficulty in accessing general medical services than in accessing psychiatric care. Individuals experiencing bipolar symptoms more frequently avoided psychiatric care because of cost (odds ratio [OR] = 2.43) and perceived greater difficulties in accessing medical specialists (OR = 2.06). Homeless individuals were more likely to report hospitalization barriers, whereas older and minority patients generally encountered fewer problems accessing treatment.

CONCLUSIONS

Need and enabling factors were most influential in predicting self-reported difficulties in accessing care, subsequently interfering with treatment dynamics and jeopardizing clinical outcomes. Efforts in the Department of Veterans Affairs to expand mental health care access should be coupled with efforts to ensure adequate access to general medical services among patients with chronic mental illnesses.

The collaborative care practice model in the long-term care of individuals with bipolar disorder: a case study

Effective therapies for the long-term care of individuals with bipolar disorder feature medication management and an interactional component between patients and care providers. In this paper, we discuss the effectiveness of applying a collaborative practice model to the long-term care of individuals with bipolar disorder who receive outpatient treatment. The model emphasizes that patients are co-managers of their illness and successful outcomes are enhanced within a supportive social environment. Key elements include joint patient-provider treatment planning and decision making. Several controlled trials have demonstrated that when the model is adopted, significant improvements in clinical and functional outcomes can be achieved. The paper concludes with a case study, which illustrates that the model can be successfully implemented in a clinical setting. Given that the clinical and research evidence demonstrates the effectiveness of the model, we suggest that advanced practice psychiatric nurses apply key elements of the collaborative practice model in their work with clients with bipolar disorder.

Therapeutic alliance perceptions and medication adherence in patients with bipolar disorder

BACKGROUND

Despite the dissemination of practice guidelines for bipolar disorder, outcomes remain suboptimal, largely due to poor treatment adherence. The episodic nature of bipolar disorder disrupts appropriate patient-provider dynamics, interfering with appropriate care. Maintaining a beneficial therapeutic alliance with providers is one important strategy for improving adherence. We examine the association between adherence and therapeutic environment perceptions among veterans with bipolar disorder.

METHODS

Participants were recruited from the Continuous Improvement for Veterans in Care--Mood Disorders (CIVIC-MD) study (N=435). Individual items and a summary score from the Health Care Climate Questionnaire (HCCQ) for bipolar disorder solicited patient evaluations of their therapeutic environment. Multivariable logistic analyses examined the association between therapeutic alliance and two measures of adherence (missed medication days and intrapersonal barriers), adjusting for relevant patient characteristics.

RESULTS

Adherence difficulty was reported on both measures, with substantial differences between perceived barriers and actual medication behavior. Significantly fewer minority veterans endorsed good adherence than white patients (59% versus 77%), although no ethnic differences were noted in therapeutic environment perceptions. Multivariable results indicated that positive therapeutic alliance was associated with better adherence (HCCQ effect sizes 13-20%). Notably, patients reporting providers encouraged "staying in regular contact" were more likely to be adherent, as were patients whose "providers regularly review their progress".

LIMITATIONS

Generalizability from observational study; adherence defined by cross-sectional patient self-report.

CONCLUSIONS

The observed association between medication adherence and therapeutic alliance with bipolar treatment supports intervention efforts to strengthen the patient-provider relationship, a bond likely to yield positive clinical outcomes.

Adherence to medication in bipolar disorder: a qualitative study exploring the role of patients' beliefs about the condition and its treatment

OBJECTIVES

Patients' perceptions of illness and treatment have been found to predict adherence to medication in many chronic conditions. This has not yet been fully explored in bipolar disorder (BD). The aim was to use a qualitative methodology to explore in depth the beliefs about BD and its treatment that are associated with adherence to medication prescribed for BD.

METHODS

Sixteen adults prescribed prophylactic treatment for BD completed semi-structured interviews about their perceptions of BD and its treatment and their adherence to medication. Interviews were recorded and transcribed verbatim. Two researchers identified perceptions associated with non-adherence in the transcripts.

RESULTS

Thirteen participants (81%) reported some degree of intentional or unintentional medication non-adherence. Intentional non-adherence was associated with patients' concerns about the prescribed medication, arising from the experience of side effects, but also from beliefs that regular use could lead to adverse effects in the future. Intentional non-adherence was also associated with doubts about the personal need for medication, which were related to perceptions of BD (e.g., not accepting diagnosis, believing the condition is not controllable, believing it is not a chronic condition).

CONCLUSIONS

This study has identified some of the salient beliefs about BD and its treatment that should be elicited and addressed in interventions to facilitate adherence to medication. Further quantitative work is justified to explore the utility of this approach in the development of interventions.

Psychotherapy through the phases of bipolar disorder: Evidence for general efficacy and differential effects

The obstacle facing pharmacotherapy for bipolar disorder is that almost half of the patients do not achieve recovery over the duration of treatment. Although the reason for this disappointing clinical outcome remains unclear, structured psychotherapy has helped to fill these gaps in the treatment of bipolar disorder. Psychoeducation, family-focused therapy, interpersonal and social rhythm therapy, and cognitive behavior therapy have all received attention in the research literature. In this review, by assessing the outcomes from randomized control trials across the phases of bipolar disorder, we demonstrate that psychotherapy is an effective adjunctive treatment. We also show that the use of psychotherapy for bipolar disorder has differential results depending on when and under what conditions it is administered.

Bipolar disorder: etiology, diagnosis, and management

PURPOSE

To review the epidemiology and disease characteristics of the bipolar disorder (BD) spectrum, render an accurate and timely diagnosis, and review treatment options through provider and patient collaboration.

DATA SOURCES

Comprehensive review of current scientific literature derived from electronic databases and professional medical references.

CONCLUSIONS

BD is a multifactorial disease that can interfere with cognition and behavior, causing a severe impact on patients and families. The variable course and often delayed diagnosis of this disorder can cause frustration for the patient and the healthcare provider. Because most undiagnosed patients with BD seek treatment within the primary care setting, it is imperative that clinicians become expert in the recognition of and intervention for this condition.

IMPLICATIONS FOR PRACTICE

The primary care provider is in a key position to render early diagnosis and treatment of BD. This disease should always be considered as part of the differential diagnosis for depression or anxiety. Nurse practitioners can be effective providers by using good nursing practices of communication, education, and advocacy for the patient and family. Knowledge of current diagnostic criteria and management is imperative for successful treatment of patients with BD.