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Verwijmeren D, Grootens KP. Shifting Perspectives on the Challenges of Shared Decision Making in Mental Health Care. Community Ment Health J 2024; 60:292-307. [PMID: 37550559 PMCID: PMC10821819 DOI: 10.1007/s10597-023-01170-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/08/2023] [Indexed: 08/09/2023]
Abstract
Although shared decision making (SDM) has become the most preferable way in doctor-patient communication, it is not fully implemented in mental health care likely due to the complex nature of psychiatric syndromes and treatments. In this review we provide a systematic overview of all perceived and reported barriers to SDM in the literature, acknowledging field-specific challenges, and offering perspectives to promote its wider use. We conducted a systematic search of the wider literature in different databases and included all publications mentioning specified barriers to SDM in psychiatric care. Relevant data and opinions were categorised into micro-, meso- and macro-level themes and put into clinical perspective. We derived 20 barriers to SDM from 100 studies and reports. Eight were on micro-level care delivery, seven involved meso-level issues, five concerned macro-level themes. The multitude of perceived and actual barriers to SDM underline the challenges its implementation poses in mental health care, some of which can be resolved while others are inherent to the nature of the care, with its long-term relationships, complex dynamics, and social consequences, all requiring a flexible approach. We present four perspectives to help change views on the potential of SDM in mental health care.
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Affiliation(s)
- Doris Verwijmeren
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Postbus 90153, 5000 LE, Tilburg, The Netherlands.
- Reinier van Arkel Mental Health Institute, 's-Hertogenbosch, The Netherlands.
| | - Koen P Grootens
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Postbus 90153, 5000 LE, Tilburg, The Netherlands
- Reinier van Arkel Mental Health Institute, 's-Hertogenbosch, The Netherlands
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2
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So YK, Chan CY, Fung SC, Lui TT, Lau FC, Chan KW, Lee HM, Lui SY, Hui LM, Chen E, Chang WC. Rates and correlates of medication non-adherence behaviors and attitudes in adult patients with early psychosis. Soc Psychiatry Psychiatr Epidemiol 2023:10.1007/s00127-023-02563-4. [PMID: 37833425 DOI: 10.1007/s00127-023-02563-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/28/2023] [Indexed: 10/15/2023]
Abstract
PURPOSE Literature on antipsychotic medication adherence in early psychosis primarily assessed adherence behaviors and focused on young patients. There is a paucity of research investigating negative medication attitude and its determinants in the early illness course, particularly in older-aged sample. We aimed to examine prevalence and correlates of medication non-adherence behaviors and negative medication attitudes separately in adult patients with early psychosis. METHODS One hundred ninety-nine Chinese early psychosis patients aged 26-55 years who had received three-year treatment for first psychotic episode in Hong Kong were examined. Assessments encompassing socio-demographics, premorbid adjustment, clinical and treatment profiles, self-stigma and therapeutic alliance were conducted. Patients were evaluated with Medication Compliance Questionnaire, which is a modified Chinese-translated version of Medication Adherence Rating Scale and includes items measuring adherence behaviors and attitudes towards medications. RESULTS Rates of medication non-adherence and negative attitude towards medications were 38.7% and 50.8%, respectively. Multivariate regression analysis showed that more severe positive symptoms, greater self-stigma and negative medication attitude were independently associated with medication non-adherence. Negative attitude towards medications was significantly associated with younger age, higher educational attainment, diagnosis of other psychotic disorders, poorer insight, greater self-stigma and less satisfaction with communication with healthcare staff, which represented an index reflecting suboptimal therapeutic alliance. CONCLUSION Antipsychotic non-adherence and negative medication attitudes are frequently observed in adult early psychosis patients. Our findings indicate that poor insight, elevated self-stigma and suboptimal therapeutic alliance may constitute potential treatment targets for promoting medication adherence and rectifying negative medication attitudes in the early illness stage.
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Affiliation(s)
- Yuen Kiu So
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Ching Yui Chan
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Shi Cheng Fung
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Tsz Ting Lui
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Fu Chun Lau
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Kit Wa Chan
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Pokfulam, Hong Kong
| | - Ho Ming Lee
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Sai Yu Lui
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Lai Ming Hui
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Eric Chen
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Pokfulam, Hong Kong
| | - Wing Chung Chang
- Department of Psychiatry, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong.
- State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Pokfulam, Hong Kong.
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3
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Lewins A, Morant N, Akther-Robertson J, Crellin NE, Stansfeld JL, Smith R, Moncrieff J. A qualitative exploration of family members' perspectives on reducing and discontinuing antipsychotic medication. J Ment Health 2022:1-8. [PMID: 35521675 DOI: 10.1080/09638237.2022.2069710] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 02/24/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Antipsychotics are routinely prescribed to people diagnosed with schizophrenia or psychosis on a long-term basis. Considerable literature explores service users' opinions and experiences of antipsychotics, but studies investigating family members' views are lacking. AIMS To explore family members' perspectives on antipsychotics, particularly their views on long-term use, reduction and discontinuation of antipsychotics. METHODS Semi-structured interviews were conducted with 11 family members of people experiencing psychosis. Participants were recruited through community support groups and mental health teams. Interviews were analysed thematically. RESULTS The majority of family members valued antipsychotic medication primarily in supporting what they saw as a fragile stability in the person they cared for. Their views of medication were ambivalent, combining concerns about adverse effects with a belief in the importance of medication due to fears of relapse. They described a need for constant vigilance in relation to medication to ensure it was taken consistently, and often found changes, particularly reduction in medication difficult to contemplate. CONCLUSIONS Findings highlight that family members' attitudes to medication sometimes conflict with those of the people they care for, impacting on their health and the caring relationship. Family members may need more support and could be usefully involved in medication decision-making.
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Affiliation(s)
- Amy Lewins
- Population Policy and Practice, UCL Great Ormond Street Institute of Child Health Population Policy and Practice, London, United Kingdom of Great Britain and Northern Ireland
| | - Nicola Morant
- Division of Psychiatry, University College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Johura Akther-Robertson
- Division of Psychiatry, University College London, London, United Kingdom of Great Britain and Northern Ireland
- NELFT Research & Development Department, North East London NHS Foundation Trust Maggie Lilley Suite, Goodmayes Hospital, London, United Kingdom of Great Britain and Northern Ireland
| | - Nadia E Crellin
- Division of Psychiatry, University College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Jacki L Stansfeld
- Division of Psychiatry, University College London, London, United Kingdom of Great Britain and Northern Ireland
- NELFT Research & Development Department, North East London NHS Foundation Trust Maggie Lilley Suite, Goodmayes Hospital, London, United Kingdom of Great Britain and Northern Ireland
| | - Ruth Smith
- Independent consultant, Brighton, United Kingdom of Great Britain and Northern Ireland
| | - Joanna Moncrieff
- Division of Psychiatry, University College London, London, United Kingdom of Great Britain and Northern Ireland
- Havering Community Recovery Team, Harold Wood, United Kingdom of Great Britain and Northern Ireland
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4
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Grünwald LM, Duddy C, Byng R, Crellin N, Moncrieff J. The role of trust and hope in antipsychotic medication reviews between GPs and service users a realist review. BMC Psychiatry 2021; 21:390. [PMID: 34348680 PMCID: PMC8340528 DOI: 10.1186/s12888-021-03355-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/26/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Increasing number of service users diagnosed with schizophrenia and psychosis are being discharged from specialist secondary care services to primary care, many of whom are prescribed long-term antipsychotics. It is unclear if General Practitioners (GPs) have the confidence and experience to appropriately review and adjust doses of antipsychotic medication without secondary care support. AIM To explore barriers and facilitators of conducting antipsychotic medication reviews in primary care for individuals with no specialist mental health input. DESIGN & SETTING Realist review in general practice settings. METHOD A realist review has been conducted to synthesise evidence on antipsychotic medication reviews conducted in primary care with service users diagnosed with schizophrenia or psychosis. Following initial scoping searches and discussions with stakeholders, a systematic search and iterative secondary searches were conducted. Articles were systematically screened and analysed to develop a realist programme theory explaining the contexts (C) and mechanisms (M) which facilitate or prevent antipsychotic medication reviews (O) in primary care settings, and the potential outcomes of medication reviews. RESULTS Meaningful Antipsychotic medication reviews may not occur for individuals with only primary care medical input. Several, often mutually reinforcing, mechanisms have been identified as potential barriers to conducting such reviews, including low expectations of recovery for people with severe mental illness, a perceived lack of capability to understand and participate in medication reviews, linked with a lack of information shared in appointments between GPs and Service Users, perceived risk and uncertainty regarding antipsychotic medication and illness trajectory. CONCLUSIONS The review identified reciprocal and reinforcing stereotypes affecting both GPs and service users. Possible mechanisms to counteract these barriers are discussed, including realistic expectations of medication, and the need for increased information sharing and trust between GPs and service users.
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Affiliation(s)
- L M Grünwald
- Division of Psychiatry, University College London, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7NF, UK.
- Comprehensive Clinical Trials Unit, 90 High Holborn, London, WC1V 6LJ, UK.
| | - C Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - R Byng
- Peninsula Medical School, University of Plymouth, Drake Circus, Plymouth, Devon, PL4 8AA, UK
| | - N Crellin
- Nuffield Trust, 59 New Cavendish Street, London, W1G 7LP, UK
| | - J Moncrieff
- Division of Psychiatry, University College London, 149 Tottenham Court Rd, Bloomsbury, London, W1T 7NF, UK
- Research and Development Department, North East London Foundation Trust, Maggie Lilley Suite, Goodmayes Hospital, Barley Lane, Ilford, Essex, IG3 8XJ, UK
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5
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Cox AD, Virues-Ortega J. Long-term functional stability of problem behavior exposed to psychotropic medications. J Appl Behav Anal 2021; 55:214-229. [PMID: 34329500 DOI: 10.1002/jaba.873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 11/06/2022]
Abstract
Psychopharmacological and behavioral interventions are often combined in the treatment of problem behavior in people with intellectual and developmental disability (IDD). However, little is known about the interaction between medication pharmacodynamics and behavior function. A better understanding of these mechanisms could serve as the conceptual foundation for combined interventions. The current analysis is a systematic replication of Valdovinos et al. (2009). We conducted continuous functional analyses within analogue reversal and parametric analyses monitoring the impact of various dosages of primarily antipsychotic medications on problem behavior and its function. Four individuals with IDD and problem behavior who were also receiving psychotropic medications participated. Medication adjustments produced small to negligible decreases in problem behavior, and behavior function remained largely unchanged through the 14 medication adjustments evaluated. The continuous functional analysis helped to identify what could be delayed medication effects on problem behavior. The clinical and methodological implications of this replication are discussed.
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Affiliation(s)
| | - Javier Virues-Ortega
- Universidad Autónoma de Madrid, Madrid, Spain.,The University of Auckland, Auckland, New Zealand
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Larsen-Barr M, Seymour F. Service-user efforts to maintain their wellbeing during and after successful withdrawal from antipsychotic medication. Ther Adv Psychopharmacol 2021; 11:2045125321989133. [PMID: 33796264 PMCID: PMC7970681 DOI: 10.1177/2045125321989133] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 12/28/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND It is well-known that attempting antipsychotic withdrawal can be a fraught process, with a high risk of relapse that often leads people to resume the medication. Nonetheless, there is a group of people who appear to be able to discontinue successfully. Relatively little is known about how people do this. METHODS A convenience sample of adults who had stopped taking antipsychotic medication for more than a year were recruited to participate in semi-structured interviews through an anonymous online survey that investigated antipsychotic medication experiences in New Zealand. Thematic analysis explored participant descriptions of their efforts to maintain their wellbeing during and after the withdrawal process. RESULTS Of the seven women who volunteered to participate, six reported bipolar disorder diagnoses and one reported diagnoses of obsessive compulsive disorder and depression. The women reported successfully discontinuing antipsychotics for 1.25-25 years; six followed a gradual withdrawal method and had support to prepare for and manage this. Participants defined wellbeing in terms of their ability to manage the impact of any difficulties faced rather than their ability to prevent them entirely, and saw this as something that evolved over time. They described managing the process and maintaining their wellbeing afterwards by 'understanding myself and my needs', 'finding what works for me' and 'connecting with support'. Sub-themes expand on the way in which they did this. For example, 'finding what works for me' included using a tool-box of strategies to flexibly meet their needs, practicing acceptance, drawing on persistence and curiosity and creating positive life experiences. CONCLUSION This is a small, qualitative study and results should be interpreted with caution. This sample shows it is possible for people who experience mania and psychosis to successfully discontinue antipsychotics and safely manage the impact of any symptoms that emerge as a result of the withdrawal process or other life stressors that arise afterwards. Findings suggest internal resources and systemic factors play a role in the outcomes observed among people who attempt to stop taking antipsychotics and a preoccupation with avoiding relapse may be counterproductive to these efforts. Professionals can play a valuable role in facilitating change.
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Affiliation(s)
| | - Fred Seymour
- School of Psychology, The University of Auckland, Auckland, New Zealand
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The Medication Experience: A Concept Analysis. PHARMACY 2020; 9:pharmacy9010007. [PMID: 33396387 PMCID: PMC7839002 DOI: 10.3390/pharmacy9010007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/27/2020] [Accepted: 12/29/2020] [Indexed: 11/17/2022] Open
Abstract
This is a concept analysis of the medication experience with a focus on how it applies to the pharmaceutical care practice framework used by pharmacist practitioners. The medication experience is a vital component of pharmaceutical care practice and of patient-centered care. Although the experience of taking medication has been studied across disciplines for decades, a concept analysis of the medication experience is lacking. Rodgers’ evolutionary concept analysis method was utilized. Ovid Medline, CINAHL, PsycINFO, Sociological Abstracts and Google Scholar databases, references and hand searches were used to compile an international dataset of 66 papers published from 1982 to 2020. As a result of the available literature, the medication experience is defined as one of ambivalence and vulnerability in which the patient is actively engaged in an ongoing process or negotiation, which is pragmatic to the ways in which they live and experience life, contextualized and nuanced within the social construction of their individual realities. The concept of medication experience is an important addition to the scientific literature. The definition of medication experience from the perspective of the patient will help to better explain the concept for future research and theory development to move the discipline of pharmaceutical care practice forward.
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8
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A qualitative study of medication adherence amongst people with schizophrenia. Arch Psychiatr Nurs 2020; 34:194-199. [PMID: 32828348 DOI: 10.1016/j.apnu.2020.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/20/2020] [Accepted: 06/02/2020] [Indexed: 12/14/2022]
Abstract
Non-adherence to antipsychotic medication is common among people with schizophrenia, and is associated with an increased risk of relapse. It is important to develop strategies to enhance medication adherence. Few qualitative studies have been undertaken to understand the consumer's perspective. The voice of people who are prescribed these medications is therefore missing from the research literature. Reasons for non-adherence were investigated by directly engaging with consumers and exploring their attitudes, beliefs and experiences concerning antipsychotic medications. Qualitative, semi- structured, one-to-one interviews were conducted with 25 community-dwelling people with schizophrenia from metropolitan Adelaide, Australia. Interviews were audio-recorded, transcribed and analysed, guided by a grounded theory approach. Codes identified in open coding were grouped into categories, reflective of the different aspects of consumers' attitudes and experiences with medication. Interviews continued until there was saturation of themes. Consumer-related factors, medication-related factors and service-related factors were reported to influence adherence behavior. These included poor insight, unpleasant medication side effects, inadequate efficacy and poor therapeutic alliance. Lessons gained during periods of non-adherence were the motivator for future adherence; such as worsening of symptoms if medication was not taken. Potential implications of future adherence described by Interviewees include greater involvement of peer workers, as they were considered to work more effectively with consumers to encourage adherence. Peer workers had more credibility than other service providers due to their lived experience. Multiple factors were identified that impact on antipsychotic medication adherence, providing opportunities for interventions and improvements in services that would enhance adherence.
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9
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Experiences of taking neuroleptic medication and impacts on symptoms, sense of self and agency: a systematic review and thematic synthesis of qualitative data. Soc Psychiatry Psychiatr Epidemiol 2020; 55:151-164. [PMID: 31875238 DOI: 10.1007/s00127-019-01819-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 12/13/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE Neuroleptic (antipsychotic) drugs reduce psychotic symptoms, but how they achieve these effects and how the drugs' effects are experienced by people who take them are less well understood. The present study describes a synthesis of qualitative data about mental and behavioural alterations associated with taking neuroleptics and how these interact with symptoms of psychosis and people's sense of self and agency. METHODS Nine databases were searched to identify qualitative literature concerning experiences of taking neuroleptic medication. A thematic synthesis was conducted. RESULTS Neuroleptics were commonly experienced as producing a distinctive state of lethargy, cognitive slowing, emotional blunting and reduced motivation, which impaired functioning but also had beneficial effects on symptoms of psychosis and some other symptoms (e.g. insomnia). For some people, symptom reduction helped restore a sense of normality and autonomy, but others experienced a loss of important aspects of their personality. Across studies, many people adopted a passive stance towards long-term medication, expressing a sense of resignation, endurance or loss of autonomy. CONCLUSIONS Neuroleptic drugs modify cognition, emotions and motivation. These effects may be associated with reducing the intensity and impact of symptoms, but also affect people's sense of self and agency. Understanding how the effects of neuroleptics are experienced by those who take them is important in developing a more collaborative approach to drug treatment in psychosis and schizophrenia.
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Moncrieff J, Gupta S, Horowitz MA. Barriers to stopping neuroleptic (antipsychotic) treatment in people with schizophrenia, psychosis or bipolar disorder. Ther Adv Psychopharmacol 2020; 10:2045125320937910. [PMID: 32670542 PMCID: PMC7338640 DOI: 10.1177/2045125320937910] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 06/03/2020] [Indexed: 12/19/2022] Open
Abstract
Most guidelines recommend long-term, indefinite neuroleptic (or antipsychotic) treatment for people with schizophrenia, recurrent psychosis or bipolar disorder, on the basis that these medications reduce the chance of relapse. However, neuroleptics have significant adverse effects, including sexual dysfunction, emotional blunting, metabolic disturbance and brain shrinkage, and patients often request to stop them. Evidence for the benefits of long-term treatment is also not as robust as generally thought. Short-term randomised trials show higher rates of relapse among those whose neuroleptic treatment is discontinued compared with those on maintenance treatment, but they are confounded by adverse effects associated with the withdrawal of established medication. Some longer-term studies show possible advantages of medication reduction and discontinuation in terms of improved social functioning and recovery. Therefore, there is a good rationale for supporting patients who wish to stop their medication, especially given the patient choice agenda favoured by The National Institute for Clinical Excellence (NICE). The major barrier to stopping antipsychotics is an understandable fear of relapse among patients, their families and clinicians. Institutional structures also prioritise short-term stability over possible long-term improvements. The risk of relapse may be mitigated by more gradual reduction of medication, but further research is needed on this. Psychosocial support for patients during the process of reducing medication may also be useful, particularly to enhance coping skills. Guidelines to summarise evidence on ways to reduce medication would be useful. Many patients want to try and stop neuroleptic medication for good reasons, and psychiatrists can help to make this a realistic option by supporting people to do it as safely as possible, with the best chance of a positive outcome.
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Affiliation(s)
- Joanna Moncrieff
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, Fitzrovia, London W1T 7BN, UK
| | - Swapnil Gupta
- Psychiatry, Yale School of Medicine, New Haven, CT, USA
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Lovell K, Bee P, Bower P, Brooks H, Cahoon P, Callaghan P, Carter LA, Cree L, Davies L, Drake R, Fraser C, Gibbons C, Grundy A, Hinsliff-Smith K, Meade O, Roberts C, Rogers A, Rushton K, Sanders C, Shields G, Walker L. Training to enhance user and carer involvement in mental health-care planning: the EQUIP research programme including a cluster RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2019. [DOI: 10.3310/pgfar07090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Service users and carers using mental health services want more involvement in their care and the aim of this research programme was to enhance service user and carer involvement in care planning in mental health services.
Objectives
Co-develop and co-deliver a training intervention for health professionals in community mental health teams, which aimed to enhance service user and carer involvement in care planning. Develop a patient-reported outcome measure of service user involvement in care planning, design an audit tool and assess individual preferences for key aspects of care planning involvement. Evaluate the clinical effectiveness and the cost-effectiveness of the training. Understand the barriers to and facilitators of implementing service user- and carer-involved care planning. Disseminate resources to stakeholders.
Methods
A systematic review, focus groups and interviews with service users/carers/health professionals informed the training and determined the priorities underpinning involvement in care planning. Data from focus groups and interviews were combined and analysed using framework analysis. The results of the systematic review, focus groups/interviews and a review of the training interventions were synthesised to develop the final training intervention. To develop and validate the patient-reported outcome measure, items were generated from focus groups and interviews, and a psychometric analysis was conducted. Patient-reported outcome measure items and a three-round consensus exercise were used to develop an audit tool, and a stated preference survey was undertaken to assess individual preferences for key aspects of care planning. The clinical effectiveness and cost-effectiveness of the training were evaluated using a pragmatic cluster trial with cohort and cross-sectional samples. A nested longitudinal qualitative process evaluation using multiple methods, including semistructured interviews with key informants involved locally and nationally in mental health policy, practice and research, was undertaken. A mapping exercise was used to determine current practice, and semistructured interviews were undertaken with service users and mental health professionals from both the usual-care and the intervention arms of the trial at three time points (i.e. baseline and 6 months and 12 months post intervention).
Results
The results from focus groups (n = 56) and interviews (n = 74) highlighted a need to deliver training to increase the quality of care planning and a training intervention was developed. We recruited 402 participants to develop the final 14-item patient-reported outcome measure and a six-item audit tool. We recruited 232 participants for the stated preference survey and found that preferences were strongest for the attribute ‘my preferences for care are included in the care plan’. The training was delivered to 304 care co-ordinators working in community mental health teams across 10 NHS trusts. The cluster trial and cross-sectional survey recruited 1286 service users and 90 carers, and the primary outcome was the Health Care Climate Questionnaire. Training was positively evaluated. The results showed no statistically significant difference on the primary outcome (the Health Care Climate Questionnaire) (adjusted mean difference –0.064, 95% confidence interval –0.343 to 0.215; p = 0.654) or secondary outcomes at the 6-month follow-up. Overall, the training intervention was associated with a net saving of –£54.00 (95% confidence interval –£193.00 to £84.00), with a net quality-adjusted life-year loss of –0.014 (95% confidence interval –0.034 to 0.005). The longitudinal process evaluation recruited 54 service users, professionals and carers, finding a failure of training to become embedded in routine care.
Limitations
Our pragmatic study was designed to improve service user and care involvement in care planning among routine community mental health services. We intervened in 18 sites with > 300 care co-ordinators. However, our volunteer sites may not be fully representative of the wider population, and we lacked data with which to compare our participants with the eligible population.
Conclusions
We co-developed and co-delivered a training intervention and developed a unidimensional measure of service user and carer involvement in care planning and an audit tool. Despite a high level of satisfaction with the training, no significant effect was found; therefore, the intervention was ineffective. There was a failure of training to become embedded and normalised because of a lack of organisational readiness to accept change. Working with NHS trusts in our ‘Willing Adopters’ programme with enhanced organisational buy-in yielded some promising results.
Future work
Research should focus on developing and evaluating new organisational initiatives in addition to training health-care professionals to address contextual barriers to service and carer involvement in care planning, and explore co-designing and delivering new ways of enhancing service users’ and carers’ capabilities to engage in care planning.
Trial registration
Current Controlled Trials ISRCTN16488358.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Karina Lovell
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Penny Bee
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Peter Bower
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Helen Brooks
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Patrick Cahoon
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | | | - Lesley-Anne Carter
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Lindsey Cree
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Linda Davies
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Richard Drake
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Claire Fraser
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Chris Gibbons
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Andrew Grundy
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Oonagh Meade
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Chris Roberts
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Anne Rogers
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Kelly Rushton
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Caroline Sanders
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Gemma Shields
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Lauren Walker
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Cooper RE, Hanratty É, Morant N, Moncrieff J. Mental health professionals' views and experiences of antipsychotic reduction and discontinuation. PLoS One 2019; 14:e0218711. [PMID: 31220160 PMCID: PMC6586401 DOI: 10.1371/journal.pone.0218711] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 06/07/2019] [Indexed: 12/24/2022] Open
Abstract
Background The widely established treatment for psychosis is long-term antipsychotic medication. However, many people stop taking this treatment, and request other options. There are also growing concerns about adverse effects, but currently no professional guidelines to support reducing or stopping these drugs. The views and experiences of individual mental health professionals around reducing and stopping antipsychotics are therefore crucial in treatment decisions. Methods We conducted 7 focus groups with prescribing psychiatrists and other members of community-based statutory mental health services in London. Participants discussed their views about, experiences, and processes of antipsychotic reduction and discontinuation. Data were analysed using thematic analysis. Results Participants acknowledged that antipsychotics can have severe adverse effects. They were generally supportive of trying to reduce these drugs to the lowest effective dose, although stopping antipsychotics was less acceptable. Prior experiences of adverse events after reduction or discontinuation meant that both were approached with caution. Reduction was also reported to be hampered by organisational and knowledge barriers. Lack of resources, pressure to discharge, and poor continuity of care were seen as organisational barriers. Knowledge barriers included inadequate evidence about who might be best suited to reduction, and lack of guidance about how this could be done safely. This meant that reduction was often prompted by patients, and sometimes actively discouraged, and stability with maintenance treatment was often favoured. Conclusions Concerns about risk and other barriers means that clinicians are often reluctant to implement reduction or discontinuation of antipsychotic medication. In order to increase the treatment options available to service users, more research and guidance on how to minimise the risks of antipsychotic reduction and discontinuation is required to enable clinicians to engage more constructively with service users requests, offering people more choice and control in managing their mental health condition.
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Affiliation(s)
- Ruth E. Cooper
- Newham Centre for Mental Health, Unit for Social and Community Psychiatry, Queen Mary University of London, London, United Kingdom
- * E-mail:
| | - Éanna Hanratty
- Research & Development Department, Goodmayes Hospital, North East London NHS Foundation Trust, Essex, United Kingdom
| | - Nicola Morant
- Division of Psychiatry, University College London, London, United Kingdom
| | - Joanna Moncrieff
- Research & Development Department, Goodmayes Hospital, North East London NHS Foundation Trust, Essex, United Kingdom
- Division of Psychiatry, University College London, London, United Kingdom
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Flore J, Kokanović R, Callard F, Broom A, Duff C. Unravelling subjectivity, embodied experience and (taking) psychotropic medication. Soc Sci Med 2019; 230:66-73. [PMID: 30978572 PMCID: PMC6529876 DOI: 10.1016/j.socscimed.2019.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/31/2019] [Accepted: 04/02/2019] [Indexed: 11/28/2022]
Abstract
This paper explores how distinctions between ‘intended’ and ‘side’ effects are troubled in personal narratives of taking psychotropic medications. Grounded in interviews with 29 participants diagnosed with mental illness in Victoria, Australia between February and December 2014, we consider how people interpret pharmaceutical compounds beyond their desired or intended effects, and how such effects shape and transform subjectivity and their relationship with their bodies. This paper contributes to recent discussions of mental illness and medication effects, informed by feminist science studies. It emphasises the co-constitution of social, affective and material relations in the context of ‘taking’ psychotropic medication. This paper discusses three key themes as important to the phenomenology of the nexus of illness and psychotropic medication: movement, ambivalence, and sociality. Our analysis demonstrates how psychotropic drugs are productive of subjectivity through their promises and potential, their unexpected harms and the institutions from which they are inseparable. Analyses accounts of mental illness using feminist science and technology studies. Focus on experiences of taking psychotropic drugs and impact on subjectivity. Moves beyond distinctions between ‘therapeutic’ and ‘side’ effects of drugs. Unique contribution to understandings of experiences of taking psychotropic drugs.
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Affiliation(s)
- Jacinthe Flore
- Social and Global Studies Centre, RMIT University, Melbourne, Australia.
| | - Renata Kokanović
- Social and Global Studies Centre, RMIT University, Melbourne, Australia; Monash Centre for Health Research and Implementation, Monash University, Melbourne, Australia
| | - Felicity Callard
- Birkbeck Institute for Social Research, Birkbeck, University of London, United Kingdom
| | - Alex Broom
- Centre for Social Research in Health, UNSW Arts and Social Sciences, The University of New South Wales, Sydney, Australia
| | - Cameron Duff
- School of Management, RMIT University, Melbourne, Australia
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Bjornestad J, Lavik KO, Davidson L, Hjeltnes A, Moltu C, Veseth M. Antipsychotic treatment – a systematic literature review and meta-analysis of qualitative studies. J Ment Health 2019; 29:513-523. [DOI: 10.1080/09638237.2019.1581352] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Jone Bjornestad
- Department of Social Studies, Faculty of Social Sciences, University of Stavanger, Stavanger, Norway
| | - Kristina O. Lavik
- Department of Psychiatry, District General Hospital of F⊘rde, F⊘rde, Norway
| | | | - Aslak Hjeltnes
- Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Christian Moltu
- Department of Psychiatry, District General Hospital of F⊘rde, F⊘rde, Norway
| | - Marius Veseth
- Department of Clinical Psychology, University of Bergen, Bergen, Norway
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Lovell K, Bee P, Brooks H, Cahoon P, Callaghan P, Carter LA, Cree L, Davies L, Drake R, Fraser C, Gibbons C, Grundy A, Hinsliff-Smith K, Meade O, Roberts C, Rogers A, Rushton K, Sanders C, Shields G, Walker L, Bower P. Embedding shared decision-making in the care of patients with severe and enduring mental health problems: The EQUIP pragmatic cluster randomised trial. PLoS One 2018; 13:e0201533. [PMID: 30133461 PMCID: PMC6104914 DOI: 10.1371/journal.pone.0201533] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/16/2018] [Indexed: 11/18/2022] Open
Abstract
Background Severe mental illness is a major driver of worldwide disease burden. Shared decision-making is critical for high quality care, and can enhance patient satisfaction and outcomes. However, it has not been translated into routine practice. This reflects a lack of evidence on the best way to implement shared decision-making, and the challenges of implementation in routine settings with limited resources. Our aim was to test whether we could deliver a practical and feasible intervention in routine community mental health services to embed shared decision-making for patients with severe mental illness, by improving patient and carer involvement in care planning. Methods We cluster randomised community mental health teams to the training intervention or usual care, to avoid contamination. Training was co-delivered to a total of 350 staff in 18 teams by clinical academics, working alongside patients and carers. The primary outcome was the Health Care Climate Questionnaire, a self-report measure of ‘autonomy support’. Primary and secondary outcomes were collected by self-report, six months after allocation. Findings In total, 604 patients and 90 carers were recruited to main trial cohort. Retention at six months was 82% (n = 497). In the main analysis, results showed no statistically significant difference in the primary outcome between the intervention and usual care at 6 months (adjusted mean difference -0.064, 95% CI -0.343 to 0.215, p = 0.654). We found significant effects on only 1 secondary outcome. Conclusions An intervention to embed shared decision-making in routine practice by improving involvement in care planning was well attended and acceptable to staff, but had no significant effects on patient outcomes. Enhancing shared decision-making may require considerably greater investment of resources and effects may only be apparent over the longer term.
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Affiliation(s)
- Karina Lovell
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Penny Bee
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Helen Brooks
- Department of Psychological Sciences, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, United Kingdom
| | - Patrick Cahoon
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Patrick Callaghan
- School of Applied Sciences, London South Bank University, London, United Kingdom
| | - Lesley-Anne Carter
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Lindsey Cree
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Linda Davies
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Richard Drake
- Division of Psychology & Mental Health, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Claire Fraser
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Chris Gibbons
- Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, United Kingdom
| | - Andrew Grundy
- School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | | | - Oonagh Meade
- School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Chris Roberts
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Anne Rogers
- Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom
| | - Kelly Rushton
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Caroline Sanders
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Gemma Shields
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Lauren Walker
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Peter Bower
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, United Kingdom
- * E-mail:
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Cocoman AM, Casey M. The Physical Health of Individuals Receiving Antipsychotic Medication: A Qualitative Inquiry on Experiences and Needs. Issues Ment Health Nurs 2018; 39:282-289. [PMID: 29333898 DOI: 10.1080/01612840.2017.1386744] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Individuals with a mental illness are reported to have a reduced life expectancy and a greater risk of being affected by preventable physical illnesses such as cardiovascular disease and Type 2 diabetes. This inquiry sought to identify the physical health beliefs, experiences and needs of individuals with mental health problems in receipt of antipsychotic medication who live in the community. A qualitative inquiry was undertaken using three focus groups in a community mental health service in Ireland with 21 participants with mental health problems who were treated with antipsychotic medication. The participants were clear about the importance of good physical health as well as good mental health. They disliked the adverse effects of antipsychotic medication and experienced many barriers in accessing general practitioners/primary care services. They also preferred to receive health advice and self-management advice from the mental health services. The participants in this study were aware of the need to engage in health protective behaviours but were often overwhelmed by their comorbid health issues and the organizational and communication barriers in accessing their general practitioners.
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Affiliation(s)
- Angela M Cocoman
- a School of Nursing and Human Sciences, Faculty of Science and Health , Dublin City University , Dublin 9, Dublin , Ireland
| | - Mary Casey
- b School of Nursing, Midwifery and Health Systems, College of Health and Agricultural Sciences , University College Dublin , Dublin , Ireland
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Freedom of Opinion and Expression: From the Perspective of Psychosocial Disability and Madness. LAWS 2018. [DOI: 10.3390/laws7010003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Britten N, Riley R, Morgan M. Resisting psychotropic medicines: a synthesis of qualitative studies of medicine-taking. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.bp.107.005165] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryThis article reports the results of a synthesis of qualitative research articles about lay perspectives on prescribed psychotropic medicines. It updates and elaborates on a model of medicine-taking developed by Pound and colleagues. In this model, the concept of resistance refers to the various ways in which people take prescribed medicines while trying to minimise their intake. The synthesis included 12 papers published since 1992. The findings are presented at the societal level, in terms of the social meanings of mental health problems and medication, and at the individual level; the latter covers active engagement and lay evaluation, as well as the outcomes of evaluation, including the doctor–patient relationship. Although it can be difficult to achieve in the current clinical environment, there is much scope for developing more concordant relationships with patients in relation to prescribing and using psychotropic medicines.
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Lloyd H, Lloyd J, Fitzpatrick R, Peters M. The role of life context and self-defined well-being in the outcomes that matter to people with a diagnosis of schizophrenia. Health Expect 2017; 20:1061-1072. [PMID: 28370942 PMCID: PMC5600238 DOI: 10.1111/hex.12548] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2017] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Conduct a deep exploration of the outcomes that matter to people with a diagnosis of schizophrenia and understand from their perspective how these outcomes can be achieved. SAMPLE AND METHODS In-depth qualitative interviews were conducted with 22 people with a diagnosis of schizophrenia. Interviews were analysed using thematic frameworks, and a realist informed theories of change approach. RESULTS Our study revealed the potential causal relationships between the context of a person's life, short-term goals and long-term outcomes. We provide a nuanced and detailed exploration of outcomes that matter for people with schizophrenia in relation to self-defined well-being. Achieving life milestones, feeling safe and outcomes related to improved physical health along with employment, a positive sense of self and psychosocial outcomes, were highly valued. For short- and long-term outcomes to be achieved, individuals required medication with minimal side-effects, cognitive behavioural therapy, family/social support and meaningful activities in their lives. Well-being was influenced by life context and short- and long-term outcomes, but in a circular nature also framed what short-term goals could be achieved. CONCLUSIONS Working with people with a diagnosis of schizophrenia to identify and achieve better outcomes will necessitate a person-centred approach. This will require an appreciation of the relationship between the statutory and non-statutory resources that are available and a consideration of an individual's current well-being status. This approach acknowledges personal strengths and encourages ownership of goals and supports self-management.
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Affiliation(s)
- Helen Lloyd
- Peninsula Medical SchoolPlymouth UniversityDevonUK
| | - Joanne Lloyd
- School of PsychologySport and ExerciseStaffordshire UniversityStoke on TrentUK
| | - Ray Fitzpatrick
- Nuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Michele Peters
- Nuffield Department of Population HealthUniversity of OxfordOxfordUK
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Morant N, Azam K, Johnson S, Moncrieff J. The least worst option: user experiences of antipsychotic medication and lack of involvement in medication decisions in a UK community sample. J Ment Health 2017; 27:322-328. [PMID: 28857636 DOI: 10.1080/09638237.2017.1370637] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Treatment decision-making that fully involves service users is an aim across medicine, including mental health. AIM To explore service users experiences of taking antipsychotic medication for psychotic disorders and their perceptions of decision-making about this. METHOD Semi-structured interviews with 20 users of community mental health services, conducted by service user researchers and analysed using thematic analysis. RESULTS Antipsychotic medication was perceived to have beneficial effects on symptoms and relapse risk, but adverse effects were prominent, including a global state of lethargy and demotivation. Weighing these up, the majority viewed antipsychotics as the least worst option. Participants were split between positions of "willing acceptance", "resigned acceptance" and "non-acceptance" of taking antipsychotics. Many felt their choices about medication were limited, due to the nature of their illness or pressure from other people. They commonly experienced their prescribing psychiatrist as not sufficiently acknowledging the negative impacts of medication on life quality and physical health concerns and described feeling powerless to influence decisions about their medication. CONCLUSION The study highlights the complexity of agendas surrounding antipsychotic medication, including the pervasive influence of coercive processes and the challenges of implementing collaborative decision-making for people with serious mental health problems.
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Affiliation(s)
- Nicola Morant
- a Division of Psychiatry , University College London , London , UK and
| | - Kiran Azam
- b North East London NHS Foundation Trust, Research & Development department, Goodmayes Hospital , Essex , UK
| | - Sonia Johnson
- a Division of Psychiatry , University College London , London , UK and
| | - Joanna Moncrieff
- a Division of Psychiatry , University College London , London , UK and.,b North East London NHS Foundation Trust, Research & Development department, Goodmayes Hospital , Essex , UK
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Medication takeovers: Covert druggings and behavioral control in Alzheimer's. Soc Sci Med 2017; 188:51-59. [PMID: 28732235 DOI: 10.1016/j.socscimed.2017.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 07/04/2017] [Accepted: 07/05/2017] [Indexed: 12/31/2022]
Abstract
Older adults consume the most prescription medication in the U.S. For those who develop Alzheimer's disease, risk of medication misuse increases with the progression of the disease. Family members commonly intervene to lessen risks by taking over the management and administering of a medication regimen. Despite the potential for grave harm around the misuse of powerful drugs, few studies provide insight into the household social context of medication use for this disease. Drawing on 60 in-depth interviews conducted in four waves over 2.5 years, this study investigates how family members administered prescription and over-the-counter medications to elders with Alzheimer's. The findings detail how family members initially created and enacted the role of proxy-administrator to avoid self-administration errors and then expanded the role to manage disruptive behaviors. During this process, family members perceived themselves as working in partnership with doctors, especially in the effort to craft a regimen that controlled the affected individual's mood and sleep/wake cycle. The paper concludes by discussing the implications that family members used medications to improve conformity to a preferred household social order. The study offers conceptual advances in understanding 1) the process of proxy-administration in Alzheimer's care and 2) the role of proxy-administrators in the medicalization of deviant behavior.
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Lloyd J, Lloyd H, Fitzpatrick R, Peters M. Treatment outcomes in schizophrenia: qualitative study of the views of family carers. BMC Psychiatry 2017; 17:266. [PMID: 28732482 PMCID: PMC5521073 DOI: 10.1186/s12888-017-1418-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 07/04/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Schizophrenia is a complex, heterogeneous disorder, with highly variable treatment outcomes, and relatively little is known about what is important to patients. The aim of the study was to understand treatment outcomes informal carers perceive to be important to people with schizophrenia. METHOD Qualitative interview study with 34 individuals and 8 couples who care for a person with schizophrenia/schizoaffective disorder. Interviews were transcribed verbatim and analysed by a thematic framework based approach. RESULTS Carers described well-recognised outcomes of importance, alongside more novel outcomes relating to: Safety (of the patient/others); insight (e.g. into non-reality of psychotic phenomena); respite from fear, distress or pain; socially acceptable behaviour; getting out of the house; attainment of life milestones; changes in personality and/or temperament; reduction of vulnerability to stress; and several aspects of physical health. CONCLUSIONS These findings have the potential to inform the development of patient- or carer- focused outcome measures that take into account the full range of domains that carers feel are important for patients.
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Affiliation(s)
- Joanne Lloyd
- School of Psychology, Sport and Exercise, Staffordshire University, Stoke on Trent, UK
| | - Helen Lloyd
- Peninsula Medical School, Plymouth University, Plymouth, Devon UK
| | - Ray Fitzpatrick
- Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF UK
| | - Michele Peters
- Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF UK
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Brooks H, Harris K, Bee P, Lovell K, Rogers A, Drake R. Exploring the potential implementation of a tool to enhance shared decision making (SDM) in mental health services in the United Kingdom: a qualitative exploration of the views of service users, carers and professionals. Int J Ment Health Syst 2017; 11:42. [PMID: 28670338 PMCID: PMC5490161 DOI: 10.1186/s13033-017-0149-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 06/12/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND As a response to evidence that mental health service users and carers expect greater involvement in decisions about antipsychotic medication choice and prescribing, shared decision-making (SDM) has increasingly come to be viewed as an essential element of person-centred care and practice. However, this aspiration has yet to be realised in practice, as service users and carers continue to feel alienated from healthcare services. Existing understanding of the factors affecting the use of tools to support SDM is limited to inter-individual influences and wider factors affecting potential implementation are underexplored. AIM To explore the potential use of a tool designed to enhance collaborative antipsychotic prescribing from the perspectives of secondary care mental health service users, carers and professionals. METHODS We conducted a qualitative study (semi-structured interviews and focus groups) using a convenience sample of 33 participants (10 mental health service users, 10 carers and 13 professionals) involved in antipsychotic prescribing in one Trust in the North of England. Participants were asked about the potential implementation of a tool to support SDM within secondary mental health services. Framework analysis incorporating the use of constant comparative method was used to analyse the data. RESULTS The study identified a divergence in the views of service users and professionals, including a previously undocumented tendency for stakeholder groups to blame each other for potential implementation failure. This dissonance was shaped by meso and macro level influences relating to paternalism, legislative frameworks, accountability and lack of resources. Participants did not identify any macro level (policy or structural) facilitators to the use of the tool highlighting the negative impact of mental health contexts. Our study indicated that inter-individual factors are likely to be most important to implementation, given their potential to transcend meso and macro level barriers. CONCLUSIONS Consideration of the meso and macro level influences identified areas for potential intervention, including challenging professionals' and service users' perceptions of each other, rebalancing the notion of accountability within services and introducing new means for service user feedback on the quality of SDM. Multi-level strategies for facilitating the implementation of tools to support SDM are also presented.
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Affiliation(s)
- Helen Brooks
- Mental Health Research Group, Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL UK
| | - Kamelia Harris
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, M13 9PL UK
| | - Penny Bee
- Mental Health Research Group, Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL UK
| | - Karina Lovell
- Mental Health Research Group, Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL UK
| | - Anne Rogers
- NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Richard Drake
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Room 3.315 Jean McFarlane Building, Oxford Road, Manchester, M13 9PL UK
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Wade M, Tai S, Awenat Y, Haddock G. A systematic review of service-user reasons for adherence and nonadherence to neuroleptic medication in psychosis. Clin Psychol Rev 2017; 51:75-95. [DOI: 10.1016/j.cpr.2016.10.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 09/09/2016] [Accepted: 10/26/2016] [Indexed: 12/18/2022]
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Deegan PE. The importance of personal medicine: A qualitative study of resilience in people with psychiatric disabilities. Scand J Public Health 2016; 66:29-35. [PMID: 16214720 DOI: 10.1080/14034950510033345] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Resilience does not refer to a magical state of invulnerability and the capacity for resilience does not end when one is diagnosed with a prolonged disorder or disease. Despite the enduring legacy of pessimism regarding resilience in the population of people diagnosed with psychiatric disorders, a majority do recover. Aim: The present study seeks to understand how people with psychiatric disorders demonstrate the capacity for resilience in the ways they use or do not use psychiatric medications in their daily lives. Method: A qualitative method and participatory action design was used to analyze interviews with 29 people diagnosed with psychiatric disorders. Results: When discussing their use of psychiatric medications, research participants also talked about non-pharmaceutical, personal medicine. Personal medicine was found to be those activities that gave life meaning and purpose, and that served to raise self-esteem, decrease symptoms, and avoid unwanted outcomes such as hospitalization. When psychiatric medications interfered with non-pharmaceutical personal medicine, non-adherence often occurred. Conclusion: People with psychiatric disorders demonstrate resilience through the use of non-pharmaceutical, personal medicine in the recovery process. This understanding suggests that medication adherence may be improved when clinicians inquire about patients' personal medicine and use pharmaceuticals to support, rather than interfere with, these self-assessed health resources.
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Bülow P, Andersson G, Denhov A, Topor A. Experience of Psychotropic Medication -An Interview Study of Persons with Psychosis. Issues Ment Health Nurs 2016; 37:820-828. [PMID: 27696916 DOI: 10.1080/01612840.2016.1224283] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Psychotropic drugs, particularly antipsychotic types, are a cornerstone of the treatment of people with psychosis. Despite numerous studies showing that drug treatment with psychotropic drugs initially alleviates psychiatric symptoms, the proportion of people with mental health problems and symptoms that do not follow doctors' prescriptions, thus exhibiting so-called non-adherence, is considerable. Non-adherence is predominantly seen as a clinical feature and as a patient characteristic that is especially due to patients' poor understanding that they are ill. There is also a widespread notion that non-adherence is of great disadvantage to the patient. This article is based on interviews with 19 persons diagnosed with psychosis. It challenges the notion of patients being either adherent or non-adherent to the doctor's orders. The findings show that persons with psychosis are active agents when it comes to adjusting medication. The interviewees created their own strategies to gain power over treatment with psychotropic drugs. The most common strategies were to adjust the doses or take breaks of varying lengths from the medication. These deviations from prescriptions were important to conceal, not only from their own psychiatrists, but from all psychiatric staff.
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Affiliation(s)
- Per Bülow
- a Department of Behavioural Science and Social Work , School of Health and Welfare, Jönköping University , Jönköping , Sweden ; Psychiatric Clinical, County Hospital Ryhov , Jönköping , Sweden ; Forensic Psychiatric Regional Clinic , Vadstena , Sweden
| | - Gunnel Andersson
- b Research and Development Unit , FoU Södertörn , Doktorsvägen 2, 147 30 Tumba , Sweden
| | - Anne Denhov
- c Research and Development Unit , Psychiatry South Stockholm , 121 05 Johanneshov, Sweden ; Department of Social Work , Stockholm University , 106 91 Stockholm, Sweden
| | - Alain Topor
- d Department of Social Work , Stockholm University , 106 91 Stockholm, Sweden ; Research and Development Unit , Psychiatry South Stockholm , 121 05 Johanneshov, Sweden ; Department of Mental Health , University of Agder , Kristiansand , Norway
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Hernandez M, Barrio C. Families and medication use and adherence among Latinos with schizophrenia. J Ment Health 2016; 26:14-20. [PMID: 27690706 DOI: 10.1080/09638237.2016.1222061] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Medication nonadherence among Latinos with schizophrenia represents a significant treatment obstacle. Although some studies have examined patient and family perceptions of adherence, few have examined these perceptions together. However, such knowledge can provide a deeper understanding of how family processes may contribute to or impede adherence among underserved groups such as Latinos. AIMS This study explored perceptions of medication and adherence among Latinos with schizophrenia and key family members. METHOD Purposive sampling was used to collect data from 34 participants: 14 patients with schizophrenia receiving community-based mental health services in an urban public setting and 20 key family members. Informed by grounded theory, semistructured interviews were analyzed by bilingual-bicultural team members. RESULTS Salient themes emerged indicating facilitators of and obstacles to medication use. Specifically, challenges centered on medication side effects, autonomy and choice, and illness insight, whereas facilitators focused on family support and holistic views of treatment and empowerment. CONCLUSIONS Because the majority of Spanish-speaking Latinos with schizophrenia live with family, it is important to examine family factors that may influence medication use. Findings suggest that patient and family perceptions of medication should be examined as part of the treatment process, particularly regarding issues of autonomy and choice.
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Affiliation(s)
- Mercedes Hernandez
- a School of Social Work, University of Southern California , Los Angeles , CA , USA
| | - Concepción Barrio
- a School of Social Work, University of Southern California , Los Angeles , CA , USA
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Morant N, Kaminskiy E, Ramon S. Shared decision making for psychiatric medication management: beyond the micro-social. Health Expect 2016; 19:1002-14. [PMID: 26260361 PMCID: PMC5053275 DOI: 10.1111/hex.12392] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Mental health care has lagged behind other health-care domains in developing and applying shared decision making (SDM) for treatment decisions. This is despite compatibilities with ideals of modern mental health care such as self-management and recovery-oriented practice, and growing policy-level interest. Psychiatric medication is a mainstay of mental health treatment, but there are known problems with prescribing practices, and service users report feeling uninvolved in medication decisions and concerned about adverse effects. SDM has potential to produce better tailoring of psychiatric medication to individuals' needs. OBJECTIVES This conceptual review argues that several aspects of mental health care that differ from other health-care contexts (e.g. forms of coercion, questions about service users' insight and disempowerment) may impact on processes and possibilities for SDM. It is therefore problematic to uncritically import models of SDM developed in other health-care contexts. We argue that decision making for psychiatric medication is better understood in a broader way that moves beyond the micro-social focus of a medical consultation. Contextualizing specific medication-related consultations within longer term relationships, and broader service systems enables recognition of the multiple processes, actors and agendas that shape how psychiatric medication is prescribed, managed and used, and which may facilitate or impede SDM. CONCLUSION A broad conceptualization of decision making for psychiatric medication that moves beyond the micro-social can account for why SDM in this domain remains a rarity. It has both conceptual and practical utility for evaluating research evidence, identifying future research priorities and highlighting fruitful ways of developing and implementing SDM in mental health care.
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Affiliation(s)
| | - Emma Kaminskiy
- Department of Psychology, Anglia Ruskin University, Cambridge, UK
| | - Shulamit Ramon
- Department of Education and Social Care, Anglia Ruskin University, Cambridge, UK
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Abstract
This article discusses medications as socially embedded phenomena, using the class of psychoactive medications as a primary example. The analytical perspective is systemic, constructivist, and critical. We suggest that the ‘rational use of drugs’ paradigm fails to appreciate various legitimate rationalities motivating medication usages and is therefore inadequate to understand the place of medications in society. Medications have complex life cycles, with diverse actors, social systems, and institutions determining who uses what medications, how, when and why. Such understanding permits analyzing medications simultaneously as entities and representations. We outline recent changes in usage patterns of psychoactive medications (notably prescriptions to children), in pharmaceutical marketing practices (notably direct-to-consumer advertising), and in the construction of knowledge about drugs (notably the role of the Internet in legitimating consumers’ viewpoints). These changes indicate that medication life cycles evolve and mutate with social and technological change. These life cycles are viewed, then, as systems – part of other social, cultural, and economic systems, themselves in constant change. This perspective provides fertile ground to raise several research questions in order to understand better the nature of medications, their effects, and their place in society.
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Abstract
AIM In this position paper, the self-efficacy model of medication adherence in chronic mental illness is presented, and its application to antipsychotic medication adherence is considered. BACKGROUND Poor adherence to antipsychotic medications is common in chronic mental illness. Major implications of this are relapse and re-hospitalisation. Several conceptual frameworks have been developed about adherence and, in some instances, have been incorporated in medication taking studies, but have resulted in inconsistent outcomes. METHOD This paper draws on a review of literature from databases to inform the development of the self-efficacy model of medication adherence. Inclusion and exclusion criteria were developed from primary and secondary research questions. RESULTS The model places the person with chronic mental illness as an active participant central to the process of medication taking. It has three components: core factors, contextual influences and a continuum. The factors comprise a central factor, self-efficacy and four interrelated supporting influences: perceived medication efficacy; access to, and relationships with, health professionals; significant other support and supported living circumstances. The factors are affected by three broad contextual influences - personal issues, medication side-effects and complexity, and social stigma - which affect the way individuals take their medications. A continuum exists between adherence and non-adherence. CONCLUSION The model positions service users at the heart of adherence by giving prominence to self-efficacy, medication efficacy and to immediate social, psychological and environmental supports. Further work is needed to validate, refine and extend the model. RELEVANCE TO CLINICAL PRACTICE For practitioners involved in prescribing and medication management in people with chronic mental illness, the model provides a theoretical framework to strengthen adherence. It highlights the need to consider broader influences on medication taking. Moreover, it places the person with chronic mental illness as an active participant at the centre of strategies to enhance adherence.
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Affiliation(s)
- Terence V McCann
- Professor of Nursing Research, School of Nursing, Midwifery, Institute of Health and Diversity, Victoria University, Melbourne, Vic., AustraliaSenior Lecturer in Sociology, Division of Nursing and Midwifery, La Trobe University, Wodonga, Vic., AustraliaResearch Officer, School of Nursing and Midwifery, Institute of Health and Diversity, Victoria University, Melbourne, Vic., Australia
| | - Eileen Clark
- Professor of Nursing Research, School of Nursing, Midwifery, Institute of Health and Diversity, Victoria University, Melbourne, Vic., AustraliaSenior Lecturer in Sociology, Division of Nursing and Midwifery, La Trobe University, Wodonga, Vic., AustraliaResearch Officer, School of Nursing and Midwifery, Institute of Health and Diversity, Victoria University, Melbourne, Vic., Australia
| | - Sai Lu
- Professor of Nursing Research, School of Nursing, Midwifery, Institute of Health and Diversity, Victoria University, Melbourne, Vic., AustraliaSenior Lecturer in Sociology, Division of Nursing and Midwifery, La Trobe University, Wodonga, Vic., AustraliaResearch Officer, School of Nursing and Midwifery, Institute of Health and Diversity, Victoria University, Melbourne, Vic., Australia
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Bhui K, Aslam RW, Palinski A, McCabe R, Johnson MRD, Weich S, Singh SP, Knapp M, Ardino V, Szczepura A. Interventions designed to improve therapeutic communications between black and minority ethnic people and professionals working in psychiatric services: a systematic review of the evidence for their effectiveness. Health Technol Assess 2016; 19:vii-xxiv, 1-173. [PMID: 25921977 DOI: 10.3310/hta19310] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Black and minority ethnic (BME) people using psychiatric services are at greater risk of non-engagement, dropout from care and not receiving evidence-based interventions than white British people. OBJECTIVES To identify effective interventions designed to improve therapeutic communications (TCs) for BME patients using psychiatric services in the UK, to identify gaps in the research literature and to recommend future research. PARTICIPANTS Black African, black Caribbean, black British, white British, Pakistani and Bangladeshi patients in psychiatric services in the UK, or recruited from the community to enter psychiatric care. Some studies from the USA included Hispanic, Latino, Chinese, Vietnamese, Cambodian and African American people. INTERVENTIONS Any that improve TCs between BME patients and staff in psychiatric services. DATA SOURCES The published literature, 'grey' literature, an expert survey, and patients' and carers' perspectives on the evidence base. Databases were searched from their inception to 4 February 2013. Databases included MEDLINE, Applied Social Sciences Index and Abstracts, The Cochrane Library, Social Science Citation Index, Allied and Complementary Medicine Database, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, EMBASE, The Campbell Collaboration and ProQuest for dissertations. REVIEW METHODS Studies were included if they reported evaluation data about interventions designed to improve therapeutic outcomes by improving communication between BME patients and psychiatric professionals. Qualitative studies and reports in the grey literature were included only if they gave a critical evaluative statement. Two members of the team selected studies against pre-established criteria and any differences were resolved by consensus or by a third reviewer, if necessary. Data were extracted independently by two people and summarised in tables by specific study designs. Studies were subjected to a narrative synthesis that included a thematic analysis contrasting populations, countries and the strength of evidence for any intervention. The components of the interventions were compared. Patient perspectives on acceptability were considered alongside quality scores and methodological strengths and weaknesses. RESULTS Twenty-one studies (19 from the published literature and two from the grey literature) met the inclusion criteria. There were 12 trials, two observational quantitative studies, three case series, a qualitative study and three descriptive case studies. Only two studies, one a pilot trial and one a case series, included economic data; in both, a favourable but weak economic case could be made for the intervention. The trials tested interventions to prepare patients for therapeutic interventions, variable levels of ethnic matching (of professional to patient), cultural adaptation of therapies, and interventions that included social community systems in order to facilitate access to services. Empowering interventions favoured by patients and carers included adapted cognitive-behavioural therapy, assessments of explanatory models, cultural consultation, ethnographic and motivational interviews, and a telepsychiatry intervention. LIMITATIONS Studies tended to have small sample sizes or to be pilot studies, and to use proxy rather than direct measures for TCs. CONCLUSIONS Empowering interventions should be further researched and brought to the attention of commissioners. Several promising interventions need further evaluative research and economic evaluations are needed. STUDY REGISTRATION The study is registered as PROSPERO CRD42011001661. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Kamaldeep Bhui
- Centre for Psychiatry, Wolfson Institute of Preventative Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rabbea'h W Aslam
- Centre for Psychiatry, Wolfson Institute of Preventative Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Andrea Palinski
- Centre for Psychiatry, Wolfson Institute of Preventative Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rose McCabe
- Centre for Psychiatry, Wolfson Institute of Preventative Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark R D Johnson
- School of Applied Social Science, Faculty of Health and Life Sciences, De Montfort University Leicester, Leicester, UK
| | - Scott Weich
- Department of Psychiatry, Warwick Medical School, University of Warwick, Coventry, UK
| | - Swaran Preet Singh
- Department of Psychiatry, Warwick Medical School, University of Warwick, Coventry, UK
| | - Martin Knapp
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Vittoria Ardino
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Ala Szczepura
- Department of Psychiatry, Warwick Medical School, University of Warwick, Coventry, UK
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Morrison P, Meehan T, Stomski NJ. Living with antipsychotic medication side-effects: the experience of Australian mental health consumers. Int J Ment Health Nurs 2015; 24:253-61. [PMID: 25529392 DOI: 10.1111/inm.12110] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The present study explores people's experience of living with antipsychotic medication side-effects. Qualitative data were gathered through semistructured interviews with 10 mental health consumers in a community care setting in Australia. The interview transcriptions were content analysed, and enhanced by combining manifest and latent content. Important contextual cues were identified through replaying the audio-recordings. Several main themes emerged from the analysis, including the impact of side-effects, attitudes to the use of medication and side-effects, and coping strategies to manage medication side-effects. Each participant reported between six and seven side-effects on average, which were often pronounced and had a major disruptive impact on their lives. Of these effects, the most commonly mentioned was sedation, which the participants described as leaving them in a 'zombie'-like state. Most participants expressed an attitude of acceptance about the side-effects. The participants' most common strategy to manage side-effects was to change the dosage of the medication. Other common side-effect management strategies involved using other medications to control side-effects, and diverse self-help techniques, the most common of which was relaxation/distraction techniques.
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Affiliation(s)
- Paul Morrison
- School of Health Professions, Murdoch University, Perth, Western Australia
| | - Tom Meehan
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,The Park, Centre for Mental Health, Brisbane, Queensland, Australia
| | - Norman Jay Stomski
- School of Health Professions, Murdoch University, Perth, Western Australia
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Cheraghi-Sohi S, Jeffries M, Stevenson F, Ashcroft DM, Carr M, Oliver K, Rogers A. The influence of personal communities on the self-management of medication taking: A wider exploration of medicine work. Chronic Illn 2015; 11:77-92. [PMID: 24920009 DOI: 10.1177/1742395314537841] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 05/08/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVES There is a lack of focus on the broader social context, networks and influences on medicine-taking as part of illness work. This work adopts a social network approach and seeks to explicate the nature of medicine-taking work that people with multiple long-term conditions (LTCs) and their social network members (SNMs) do in attempting to take their medications on a daily basis, the division of labour amongst these members and when and why SNMs become involved in that work. METHODS Semi-structured interviews were conducted with 20 people who had multiple LTCs. Medication networks were constructed and the division of labour in relation to medication-work was explored. RESULTS Four types of medication-work emerged: medication articulation, surveillance, emotional and informational. Involvement of SNMs in medication-work was selective, performed primarily by family members, within the home. Involvement reflected network composition and/or an individual's conceptualisation/presentation of self. DISCUSSION Our findings support and extend the conceptualisation of routine medicine-taking as a type of work. Furthermore, we illustrate the involvement of SNMs in aspects of medicine-work. Health professionals should explore and support the role of SNMs in medicine-taking where possible. Future research should explore the implications of network types and compositions on medicine-taking and associated work.
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Affiliation(s)
- Sudeh Cheraghi-Sohi
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health, The University of Manchester, Manchester, United Kingdom
| | - Mark Jeffries
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health, The University of Manchester, Manchester, United Kingdom
| | | | - Darren M Ashcroft
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health, The University of Manchester, Manchester, United Kingdom
| | - Matthew Carr
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health, The University of Manchester, Manchester, United Kingdom
| | - Kathryn Oliver
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Institute of Population Health, The University of Manchester, Manchester, United Kingdom
| | - Anne Rogers
- University of Southampton, Southampton, United Kingdom
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Abstract
PURPOSE OF REVIEW The term 'schizophrenia' has been hotly contested over recent years. The current review explores the meanings of the term, whether it is valid and helpful and how alternative conceptions of severe mental disturbance would shape clinical practice. RECENT FINDINGS Schizophrenia is a label that implies the presence of a biological disease, but no specific bodily disorder has been demonstrated, and the language of 'illness' and 'disease' is ill-suited to the complexities of mental health problems. Neither does the concept of schizophrenia delineate a group of people with similar patterns of behaviour and outcome trajectories. This is not to deny that some people show disordered speech and behaviour and associated mental suffering, but more generic terms, such as 'psychosis' or just 'madness', would be preferable because they are less strongly associated with the disease model, and enable the uniqueness of each individual's situation to be recognized. SUMMARY The disease model implicit in current conceptions of schizophrenia obscures the underlying functions of the mental health system: the care and containment of people who behave in distressing and disturbing ways. A new social framework is required that makes mental health services transparent, fair and open to democratic scrutiny.
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Moral discourses and pharmaceuticalised governance in households. Soc Sci Med 2015; 131:272-9. [DOI: 10.1016/j.socscimed.2014.03.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 02/26/2014] [Accepted: 03/07/2014] [Indexed: 11/23/2022]
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Liamputtong P, Haritavorn N, Kiatying-Angsulee N. Local discourse on antiretrovirals and the lived experience of women living with HIV/AIDS in Thailand. QUALITATIVE HEALTH RESEARCH 2015; 25:253-263. [PMID: 25212858 DOI: 10.1177/1049732314550005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Antiretrovirals (ARVs) have been seen as life-saving for HIV-positive people. However, ARVs have a darker side. Since 2000, many HIV-positive people in Thailand have received ARV treatments, but the understanding of ARVs and practices of medication-taking among HIV-positive women have not received much attention. We discuss local discourses employed by HIV-positive women and health work by these individuals in their attempts to adhere to ARVs restrictions. The local discourse of ARVs was ya tan rok AIDS "medications that could resist HIV/AIDS." ARVs provided hope for the women. Although the women were affected by the side effects of ARVs, they continued to take their medication to be able to live longer and perform their duties as mothers and carers. They were more concerned about the practice of medication-taking. Understanding why these women were adherent to their ARVs offers insights into the social impact of these ARVs on their lives.
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del Barrio LR, Cyr C, Benisty L, Richard P. Gaining Autonomy & [corrected] Medication Management (GAM): new perspectives on well-being, quality of life and psychiatric medication. CIENCIA & SAUDE COLETIVA 2014; 18:2879-87. [PMID: 24061014 DOI: 10.1590/s1413-81232013001000012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 05/19/2013] [Indexed: 11/21/2022] Open
Abstract
Autonomous Medication Management (GAM) is an innovative approach developed in partnership with medication users. It takes their subjective experience into account and strives to place the individual at the center of pharmacological treatment in psychiatry with a view to improving well-being and quality of life. It creates spaces of open dialogue on the issue of medication amongst users, physicians and their family and friends. This article is derived from a research study and presents the principles, practices and main impacts of GAM on how people relate to their medications and the physicians who prescribe them. The major positive effects were the users' clearer understanding of their experience of taking psychiatric medication and their rights, the reduction or elimination of sudden and unsupervised treatment interruptions and the users' sense of having more control over their treatment. It includes inner experience and life, an improved relationship with professionals and space for negotiation with the physician and, lastly, changes to prescriptions that significantly improved well-being and recovery. The distinguishing features of GAM are described and compared with other approaches, giving a voice to people who take medication.
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Hypertensive patients' preferences for complementary and alternative medicine and the influence of these preferences on the adherence to prescribed medication. Complement Ther Clin Pract 2014; 20:99-105. [DOI: 10.1016/j.ctcp.2014.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 02/10/2014] [Accepted: 03/05/2014] [Indexed: 12/14/2022]
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Zugno AI, Julião RF, Budni J, Volpato AM, Fraga DB, Pacheco FD, Deroza PF, Luca RD, de Oliveira MB, Heylmann AS, Quevedo J. Rivastigmine reverses cognitive deficit and acetylcholinesterase activity induced by ketamine in an animal model of schizophrenia. Metab Brain Dis 2013; 28:501-8. [PMID: 23775300 DOI: 10.1007/s11011-013-9417-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 05/28/2013] [Indexed: 01/27/2023]
Abstract
Schizophrenia is one of the most disabling mental disorders that affects up to 1 % of the population worldwide. Although the causes of this disorder remain unknown, it has been extensively characterized by a broad range of emotional, ideational and cognitive impairments. Studies indicate that schizophrenia affects neurotransmitters such as dopamine, glutamate and acetylcholine. Recent studies suggest that rivastigmine (an acetylcholinesterase inhibitor) is important to improve the cognitive symptoms of schizophrenia. Therefore, the present study evaluated the protective effect of rivastigmine against the ketamine-induced behavioral (hyperlocomotion and cognitive deficit) and biochemical (increase of acetylcholinesterase activity) changes which characterize an animal model of schizophrenia in rats. Our results indicated that rivastigmine was effective to improve the cognitive deficit in different task (immediate memory, long term memory and short term memory) induced by ketamine in rats. Moreover, we observed that rivastigmina reversed the increase of acetylcholinesterase activity induced by ketamine in the cerebral cortex, hippocampus and striatum. However, rivastigmine was not able to prevent the ketamine-induced hyperlocomotion. In conslusion, ours results indicate that cholinergic system might be an important therapeutic target in the physiopathology of schizophrenia, mainly in the cognition, but additional studies should be carried.
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Affiliation(s)
- Alexandra I Zugno
- Laboratório de Neurociências, Instituto Nacional de Ciência e Tecnologia Translacional em Medicina (INCT-TM), and Núcleo de Excelência em Neurociências Aplicadas de Santa Catarina (NENASC), Programa de Pós-Graduação em Ciências da Saúde, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, 88806-000, Criciúma, SC, Brazil.
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Hassan L, Edge D, Senior J, Shaw J. Staff and patient perspectives on the purpose of psychotropic prescribing in prisons: care or control? Gen Hosp Psychiatry 2013; 35:433-8. [PMID: 23433823 DOI: 10.1016/j.genhosppsych.2013.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 01/22/2013] [Accepted: 01/22/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective was to explore perspectives on reasons for psychotropic medication use in prisons. METHOD We recruited a purposive sample of healthcare staff and patients prescribed psychotropic medicines from four East of England prisons. Participants took part in qualitative, semistructured interviews, which were recorded, transcribed and analyzed thematically. RESULTS While patients and healthcare staff viewed psychotropic medicines primarily as a treatment for reducing symptoms of mental illness, they were also used as a coping strategy and to reduce insomnia. Appropriate psychotropic prescribing was also thought to contribute towards the rehabilitation agenda and helped to maintain order in prisons. Staff voiced concerns regarding possible overreliance on psychotropic medicines. However, patients perceived insufficient access to alternative, nonpharmacological forms of treatment and support in prison. CONCLUSION Psychotropic medicines are used for multiple purposes in prisons and are generally considered a useful resource. Nonetheless, further work may be needed to find the right balance between psychotropic medicines and alternative, nonpharmacological therapies.
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Affiliation(s)
- Lamiece Hassan
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester M13 9PL.
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Chang YT, Tao SG, Lu CL. Qualitative inquiry into motivators for maintaining medication adherence among Taiwanese with schizophrenia. Int J Ment Health Nurs 2013; 22:272-8. [PMID: 22882876 DOI: 10.1111/j.1447-0349.2012.00864.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Medication non-adherence is associated with higher rates of relapse in persons with schizophrenia. Psychiatric nurses play a significant role in facilitating their medication adherence. The motivators which strengthen patients with schizophrenia to maintain their adherence to medication have seldom been explored. This study aims to explore what motivates persons with schizophrenia to consistently maintain their medication adherence. A qualitative approach was used to collect data from a psychiatric day-care centre at an armed forces hospital in Taiwan. Ten clients agreed to undergo an in-depth interview. The data was analyzed by a content analysis method. Four themes were identified: (i) the benefits of antipsychotic medication treatment; (ii) firm and ongoing family support; and the Chinese values of (iii) filial piety and (iv) hope for the future. These findings may provide psychiatric nurses with a better understanding of the motivators for medication adherence in persons with schizophrenia from the Chinese perspective. Nurses will then be able to adjust their practice to facilitate patients' medication adherence.
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Affiliation(s)
- Ying-Tzu Chang
- Department of Nursing, Buddhist Tzu Chi College of Technology, Hualien City, Taiwan.
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Ushie BA, Jegede AS. The paradox of family support: concerns of tuberculosis-infected HIV patients about involving family and friends in their treatment. AIDS Patient Care STDS 2012; 26:674-80. [PMID: 23072439 DOI: 10.1089/apc.2011.0304] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite the widely documented evidence that family support improves adherence to HIV treatment, some studies have reported no benefit or even a negative association between family support and adherence. This study reexamined the role of family support in treatment adherence to find out the circumstances under which family support for HIV and tuberculosis coinfected patients promotes or hinders treatment adherence in Cross River State, Nigeria. We conducted eight focus group discussions (FGDs) and four case histories with coinfected patients. In addition, 21 in-depth interviews (IDIs) were conducted with: 8 family members, 6 friends, and 7 care providers. Data were analyzed in a thematic format with the aid of NVIVO software. Overall, family support promotes adherence in coinfected patients. Family support may, however, have a negative effect on adherence when the recipient perceives that the support is given with ulterior motives (e.g., gossiping about them and becoming indebted to the support givers) and when the recipient is the primary breadwinner and feels that this role is being undermined. Family support is useful as a tool for scaling up adherence but the usefulness is context-specific and mediated by the patient's subjective interpretation of the support givers' motives.
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Affiliation(s)
- Nev Jones
- Department of Psychology, DePaul University, Chicago, IL 60614, USA.
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Ramalho-de Oliveira D, Shoemaker SJ, Ekstrand M, Alves MR. Preventing and resolving drug therapy problems by understanding patients' medication experiences. J Am Pharm Assoc (2003) 2012; 52:71-80. [PMID: 22257619 DOI: 10.1331/japha.2012.10239] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To provide tools for pharmacists to uncover patients' medication experiences and to discuss strategies that medication therapy management (MTM) pharmacists use to prevent and resolve drug therapy problems rooted in patients' medication experiences. DESIGN Qualitative study. SETTING Health care delivery system in the Minneapolis/Saint Paul, MN, area from January to October 2010. PARTICIPANTS 10 MTM pharmacists. INTERVENTION Thematic analysis of data from a focus group of MTM pharmacists and an MTM pharmacist's practice diary. RESULTS Patients' medication experiences were revealed as a foundational aspect of MTM pharmacists' daily practices because they had to take these experiences into consideration to be effective practitioners. According to MTM pharmacists, patients express attitudes toward drug therapy in many different ways, thereby affecting how each patient takes his/her medications. Patients' medication experiences often were at the root of drug therapy problems (DTPs). From MTM pharmacists' examples, we identified DTPs at the root of patients' medication experiences and several strategies used by pharmacists to address patients' needs and concerns regarding medications. MTM pharmacists approached patients in a nonjudgmental way so that patients would feel comfortable sharing their perspectives and goals. After understanding patients' motivations and the basis of their attitudes and decision making, pharmacists could negotiate the process of behavioral change, if needed. CONCLUSION If pharmacists understand patients' medication experiences, they may be able to address and resolve DTPs to ultimately improve therapeutic outcomes and reduce adverse events.
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Steger KA, Cassidy C, Rabinovitch M, Joober R, Malla A. Impact of symptom resolution on medication adherence in first episode psychosis. Psychiatry Res 2012; 196:45-51. [PMID: 22377571 DOI: 10.1016/j.psychres.2011.10.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Revised: 08/13/2011] [Accepted: 10/18/2011] [Indexed: 10/28/2022]
Abstract
Adequate adherence to medication confers benefits on patients with psychotic illness, but is difficult to achieve. Efficacy of medication influences adherence in patients in advanced phases of illness and may have a similar influence on patients with a first episode of psychosis (FEP). We assessed medication adherence and efficacy in 216 FEP patients at program entry and at 3 and 6 months later. "Efficacy" was evaluated as the ability of medication to reduce positive or negative symptoms to below established thresholds for clinical remission at each evaluation. Adherence was defined as adequate (>75%) or not. Resolution of negative symptoms by month 3 of treatment was associated with inadequate adherence at months 3 and 6. In contrast, rapid resolution of positive symptoms showed no relationship to adherence. In a multivariate analysis taking into account other determinants of adherence in FEP, the role of early negative symptom remission was confirmed, and we found that a 3-month sustained remission of positive symptoms was associated with adequate adherence. Medication efficacy may promote adherence if it produces sustained remission of positive symptoms. However, many patients who benefit from medication, particularly those with rapid improvement of negative symptoms, fail to adhere to the treatment.
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Quirk A, Chaplin R, Lelliott P, Seale C. How pressure is applied in shared decisions about antipsychotic medication: a conversation analytic study of psychiatric outpatient consultations. SOCIOLOGY OF HEALTH & ILLNESS 2012; 34:95-113. [PMID: 21812791 DOI: 10.1111/j.1467-9566.2011.01363.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The professional identity of psychiatry depends on it being regarded as one amongst many medical specialties and sharing ideals of good practice with other specialties, an important marker of which is the achievement of shared decision-making and avoiding a reputation for being purely agents of social control. Yet the interactions involved in trying to achieve shared decision-making are relatively unexplored in psychiatry. This study analyses audiotapes of 92 outpatient consultations involving nine consultant psychiatrists focusing on how pressure is applied in shared decisions about antipsychotic medication. Detailed conversation analysis reveals that some shared decisions are considerably more pressured than others. At one end of a spectrum of pressure are pressured shared decisions, characterised by an escalating cycle of pressure and resistance from which it is difficult to exit without someone losing face. In the middle are directed decisions, where the patient cooperates with being diplomatically steered by the psychiatrist. At the other extreme are open decisions where the patient is allowed to decide, with the psychiatrist exerting little or no pressure. Directed and open decisions occurred most frequently; pressured decisions were rarer. Patient risk did not appear to influence the degree of pressure applied in these outpatient consultations.
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Affiliation(s)
- Alan Quirk
- Royal College of Psychiatrists Centre for Quality Improvement, London, UK.
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Izugbara CO, Wekesa E. Beliefs and practices about antiretroviral medication: a study of poor urban Kenyans living with HIV/AIDS. SOCIOLOGY OF HEALTH & ILLNESS 2011; 33:869-883. [PMID: 21371051 DOI: 10.1111/j.1467-9566.2010.01328.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Interest in medication-taking as a social behaviour is growing. Drawing on qualitative data, this study interrogates beliefs and practices related to antiretroviral therapy (ART) use among urban poor Kenyan people living with HIV/AIDS (PLWHA). Responding PLWHA relied on a range of ingenious strategies to remember to take their medications but did not necessarily perceive compliance with medical instructions as key to treatment efficacy. They also believed that compliance can even hurt some patients. PLWHA relied on both compliance and non-compliance to seek social acceptance, maintain a reputation of being healthy, dispel rumours about one's status, and minimise economic vulnerability. Compliance was further used to mark gratitude to supportive caregivers and providers, and non-compliance to appraise the efficacy of other treatments which promise permanent cure. The medication-taking practices of poor Kenyan PLWHA reflect their struggles with deprived livelihoods and stigma.
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Gearing RE, Townsend L, MacKenzie M, Charach A. Reconceptualizing medication adherence: six phases of dynamic adherence. Harv Rev Psychiatry 2011; 19:177-89. [PMID: 21790266 DOI: 10.3109/10673229.2011.602560] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Nonadherence is the Achilles' heel of effective psychiatric treatment. It affects the resolution of mental health symptoms and interferes with the assessment of treatment response. The meaning of the term adherence has evolved over time and is now associated with a variety of definitions and measurement methods. The result has been a poorly operationalized and nonstandardized term that is often interpreted differently by providers and patients. Drawing extensively from the literature, this article aims to (1) describe changes in the concept of adherence, drawing from the mental health treatment literature, (2) present a more comprehensive definition of adherence that recognizes the role of patient-provider transactions, (3) introduce dynamic adherence, a six-phase model, which incorporates the role of transactional processes and other factors that influence patients' adherence decisions, and (4) provide recommendations for providers to improve adherence as well as their relationships with patients.
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Affiliation(s)
- Robin E Gearing
- Columbia University School of Social Work, New York, NY 10027, USA
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