Adherence to antipsychotic and nonpsychiatric medications in middle-aged and older patients with psychotic disorders

Association between the number of acute episodes and increased cardiac left ventricular mass index in patients diagnosed with schizophrenia

Patients with schizophrenia have a high risk of cardiovascular death. Increased cardiac left ventricular (LV) mass has been reported to be associated with heart failure and cardiac mortality. However, few studies have used echocardiographic imaging to evaluate the associations between cardiac LV mass and the clinical characteristics of schizophrenia. We recruited 121 adults to undergo standard and two-dimensional speckle-tracking echocardiography. Cardiac LV mass was determined using the Devereux formula and indexed with reference to the body surface area to obtain the cardiac LV mass index (LVMI). Clinical and demographic data were obtained through interviews and chart review. The results showed that relative to the mentally healthy controls (n = 55), individuals with schizophrenia (n = 66) had significantly higher mean values of cardiac LVMI as well as lower mitral valve E/A ratio, LV ejection fraction, and LV global longitudinal strain. Among the individuals with schizophrenia, cardiac LVMI was positively correlated with the number of acute episodes, and this association remained significant after adjustment for age, age at onset, and body mass index. On the contrary, there were no significant associations between cardiac LVMI and traditional cardiovascular risk factors. Taken together, this study suggests that the burden of psychotic symptoms may contribute to the increased risk of cardiac hypertrophy in individuals with schizophrenia independent of traditional cardiovascular risk factors. Because cardiac hypertrophy is among the major risk factors of heart failure and cardiac mortality, future research must investigate the mechanisms underlying the association between psychosis and increased cardiac LV mass.

Pathophysiological Mechanisms of Psychosis-Induced Atrial Fibrillation: The Links between Mental Disorder and Arrhythmia

Atrial fibrillation (AF) is a common phenomenon of sustained arrhythmia leading to heart failure or stroke. Patients with mental disorders (MD), particularly schizophrenia and bipolar disorder, are at a high risk of AF triggered by the dysregulation of the autonomic nervous system, atrial stretch, oxidative stress, inflammation, and electrical or structural remodeling. Moreover, pathophysiological mechanisms underlying MD may also contribute to the genesis of AF. An overactivated hypothalamic-pituitary-adrenal axis, aberrant renin-angiotensin-aldosterone system, abnormal serotonin signaling, disturbed sleep, and genetic/epigenetic factors can adversely alter atrial electrophysiology and structural substrates, leading to the development of AF. In this review, we provide an update of our collective knowledge of the pathophysiological and molecular mechanisms that link MD and AF. Targeting the pathogenic mechanisms of MD-specific AF may facilitate the development of therapeutics that mitigate AF and cardiovascular mortality in this patient population.

Adherence of patients with schizophrenia to hypothyroidism treatment

Adherence to prescription medications is critical for both remission from schizophrenia and control of physical comorbidities. While schizophrenia with comorbid hypothyroidism is common, there is little research on adherence to hypothyroidism treatment in this population. The current study used a retrospective, matched case-control design. The cohort included 1,252 patients diagnosed with schizophrenia according to ICD-10 and 3,756 controls matched for gender, age, socioeconomic status and ethnicity without diagnosis of schizophrenia. All data were retrieved from the electronic medical database of a large health maintenance organization. Retrieved data included demographics, thyroid functionality test results and prescribed medications. Measures of adherence to therapy were used for analyses as were data from follow-ups of patients with hypothyroidism. A diagnosis of hypothyroidism was found in 299 patients, 115 of whom were also diagnosed with schizophrenia. The 184 without schizophrenia constituted the control group. No statistically significant differences were found between the two groups regarding prescriptions for L-thyroxin and TSH levels and number of TSH tests. Adherence of patients with schizophrenia to hypothyroidism treatment was found to be as good as that of individuals without a schizophrenia diagnosis.

Behavioral Interventions to Reduce Cardiovascular Risk Among People with Severe Mental Disorder

Cardiovascular disease (CVD) is the leading cause of death among people with severe mental disorder (SMD). CVD risk factors occur at the individual, health system, and socio-environmental levels and contribute not only to high rates of CVD but also to worsening mental health. While acknowledging this wider context, this review focuses on behavioral interventions for seven CVD risk behaviors-smoking, physical inactivity, excessive alcohol consumption, low fruit and vegetable intake, inadequate sleep, poor social participation, and poor medication adherence-that are common among people with SMD. We survey recent meta-reviews of the literature and then review additional key studies to provide clinical recommendations for behavioral interventions to reduce CVD risk among people with SMD. A transdiagnostic psychological approach from the start of mental health treatment, drawing upon multidisciplinary expertise to address multiple risk behaviors, is recommended. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Antipsychotics Use Is Associated With Greater Adherence to Cardiometabolic Medications in Patients With Schizophrenia: Results From a Nationwide, Within-subject Design Study

BACKGROUND

People with schizophrenia/schizoaffective disorder (schizophrenia) die early, largely due to cardiovascular-related mortality. Antipsychotics are associated with lower mortality. We aimed to explore whether antipsychotic use can reduce discontinuation of medications for cardiovascular risk factors and diseases ("cardiometacolic drugs"), using a within-study design controlling for subject-related factors.

METHODS

Persons diagnosed with schizophrenia between 1972 and 2014, aged <65 years at cohort entry were identified in Finnish national databases. Four subcohorts were formed based on cardiometabolic drug use during the follow-up period, 1996-2017, namely statin (n = 14,047), antidiabetic (n = 13,070), antihypertensive (n = 17,227), and beta-blocker (n = 21,464) users. To control for subject-related factors, including likelihood of adherence as a trait characteristic, we conducted a within-subject study comparing the risk of discontinuation of each cardiometabolic drug during periods on vs off antipsychotics within each subject. We also accounted for number of psychiatric and nonpsychiatric visits in sensitivity analyses.

RESULTS

In 52,607 subjects with schizophrenia, any antipsychotic use vs nonuse was associated with decreased discontinuation risk of antidiabetics (adjusted hazard ratio [aHR] = 0.56, 95% confidence interval [CI] = 0.47-0.66), statins (aHR = 0.61, 95%CI = 0.53-0.70), antihypertensives (aHR = 0.63, 95%CI = 0.56-0.71), and beta-blockers (aHR = 0.79, 95%CI = 0.73-0.87). Antipsychotics ranking best for discontinuation of all cardiometabolic drug categories were clozapine (aHR range = 0.34-0.55), followed by olanzapine (aHR = 0.43-0.71). For statins, aHRs ranged from aHR = 0.30 (95%CI = 0.09-0.98) (flupentixol-long-acting injectable (LAI) to aHR = 0.71 (95%CI = 0.52-0.97) (risperidone-LAI), for anti-diabetic medications from aHR = 0.37 (95%CI = 0.28-0.50) (clozapine) to aHR = 0.70 (95%CI = 0.53-0.92) (quetiapine), for antihypertensives from aHR = 0.14 (95%CI = 0.04-0.46) (paliperidone-LAI) to aHR = 0.69 (95%CI = 0.54-0.88) (perphenazine), for beta-blockers from aHR = 0.55 (95%CI = 0.48-0.63) (clozapine) to aHR = 0.76 (95%CI = 0.59-0.99) (perphenazine-LAI). The decreased risk of discontinuation associated with antipsychotic use somewhat varied between age strata. Sensitivity analyses confirmed main findings.

DISCUSSION

In this national database within-subject design study, current antipsychotic use was associated with substantially decreased risk of discontinuation of statins, anti-diabetics, antihypertensives, and beta-blockers, which might explain reduced cardiovascular mortality observed with antipsychotics in people with schizophrenia.

Treatment of Patients with Mental Illness Amid A Global COVID-19 Pandemic

A newly discovered coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused the ongoing pandemic of coronavirus disease 2019 (COVID-19), which is not only physically challenging but also has many subtle and overt mental impacts. The concern of being infected, lack of antiviral agents, preventive strategies of social distancing, and home isolation have created unrest in the society. The way of reacting to emergencies varies from individual to individual, and that this variability lies in our unique personality traits. The COVID-19 pandemic is testing the mental stability of all of us, and hence it is crucial to recognize the vulnerable population and support them to prevent or minimize the catastrophe like post-traumatic stress disorder (PTSD), emotional trauma, and suicides. In this context, the role of psychiatrists, psychotherapists, and other mental healthcare providers is indispensable.

Long-acting injectable antipsychotics: what, when, and how

Current guidelines for the treatment of patients with schizophrenia advocate that patients receive treatment with a long-acting injectable (LAI) antipsychotic medication if they prefer such treatment or if they have a history of poor or uncertain adherence. Available LAI formulations in the United States include first-generation antipsychotics (fluphenazine decanoate and haloperidol decanoate), risperidone/paliperidone containing products (risperidone microspheres, paliperidone palmitate, and risperidone subcutaneous), aripiprazole containing products (aripiprazole monohydrate and aripiprazole lauroxil), and olanzapine pamoate. LAI antipsychotics can address the guesswork about adherence status and patients may prefer them if they are offered this as a choice, including individuals early in their disease course. Additional approved indications in the United States for LAI antipsychotics include bipolar I disorder maintenance treatment for risperidone microspheres and aripiprazole monohydrate, and schizoaffective disorder for paliperidone palmitate once monthly. Differences and similarities among the different products are discussed, including guidance regarding optimal treatment selection. Tips are provided to enhance effective patient communication to maximize the likelihood of acceptance of this treatment modality.

Metabolic syndrome among older adults with schizophrenia spectrum disorder: Prevalence and associated factors in a multicenter study

Metabolic syndrome and its associated morbidity and mortality have been well documented in adults with schizophrenia. However, data is lacking for their geriatric counterparts. We sought to investigate the frequency of screening and the prevalence of metabolic syndrome in older adults with schizophrenia, as well as its possible correlates, using the Cohort of individuals with schizophrenia Aged 55 years or more study (n = 353). We found that 42.2% (n = 149) of our sample was screened for metabolic syndrome. Almost half of those (n = 77; 51.7%) screened positive according to ATPIII criteria. Hypertension and abdominal obesity were the two most prevalent metabolic abnormalities. Screening was positively associated with male gender and urbanicity, and metabolic syndrome diagnosis was positively associated with cardiovascular disorders and consultation with a general practitioner (all p < 0.05). However, there were no significant associations of metabolic syndrome with socio-demographic or clinical characteristics, psychotropic medications, other medical conditions and other indicators of mental health care utilization. Our findings support that the prevalence of metabolic syndrome among older adults with schizophrenia spectrum disorder is high and screening is crucial mainly in those patients with hypertension and/or abdominal obesity. Factors at play might be different than those in the younger population.

[Psychiatric pharmacotherapy of older individuals with severe mental illness]

BACKGROUND

Chronic schizophrenia, depression, and bipolar disorders, among other chronic psychiatric disorders with onset at youth or early adulthood are often referred to as severe mental illness (SMI). Aging with SMI is associated with various psychosocial, physiological, and medical problems with potential impact on psychiatric pharmacotherapy.

OBJECTIVES

Determination and discussion of problems and special features of the psychopharmacological treatment of older persons with SMI and presentation of treatment recommendations for the distinct diagnoses.

MATERIALS AND METHODS

International literature and guidelines were searched. In addition, the basic literature and expert opinions are discussed.

RESULTS

General problems that influence the psychiatric pharmacotherapy of older persons with SMI include nonadherence, nonresponse, polypharmacy, and distinct pharmacokinetic changes with aging and somatic comorbidity. Psychotropic drugs may exhibit cardiovascular, metabolic, and neuropsychiatric risks, among others. The literature regarding effectiveness of psychotropic drugs, drug groups, or combination of drugs in older patients with SMI is scarce to nonexistent.

CONCLUSIONS

Drug treatment of older persons with SMI should be part of an overall treatment plan that also has to include social and psychotherapeutic components that address the specific problems of this population. Most importantly, psychiatric pharmacotherapy should consider these risks and the treatment should be tailored to a patient's individual risk profile. Due to a general lack of evidence in this special population, treatment strategies of standard guidelines should be adjusted with special consideration to physiological changes of age.

Medication Adherence Patterns Among Patients with Multiple Serious Mental and Physical Illnesses

INTRODUCTION

Patients with mental and physical health conditions are complex to treat and often use multiple medications. It is unclear how adherence to one medication predicts adherence to others. A predictive relationship could permit less expensive adherence monitoring if overall adherence could be predicted through tracking a single medication.

METHODS

To test this hypothesis, we examined whether patients with multiple mental and physical illnesses have similar adherence trajectories across medications. Specifically, we conducted a retrospective cohort analysis using health insurance claims data for enrollees who were diagnosed with a serious mental illness, initiated an atypical antipsychotic, as well as an SSRI (to treat serious mental illness), biguanides (to treat type 2 diabetes), or an ACE inhibitor (to treat hypertension). Using group-based trajectory modeling, we estimated adherence patterns based on monthly estimates of the proportion of days covered with each medication. We measured the predictive value of the atypical antipsychotic trajectories to adherence predictions based on patient characteristics and assessed their relative strength with the R-squared goodness of fit metric.

RESULTS

Within our sample of 431,591 patients, four trajectory groups were observed: non-adherent, gradual discontinuation, stop-start, and adherent. The accuracy of atypical antipsychotic adherence for predicting adherence to ACE inhibitors, biguanides, and SSRIs was 44.5, 44.5, and 49.6%, respectively (all p < 0.001 vs. random). We also found that information on patient adherence patterns to atypical antipsychotics was a better predictor of patient adherence to these three medications than would be the case using patient demographic and clinical characteristics alone.

CONCLUSION

Among patients with multiple chronic mental and physical illnesses, patterns of atypical antipsychotic adherence were useful predictors of adherence patterns to a patient's adherence to ACE inhibitors, biguanides, and SSRIs.

FUNDING

Otsuka Pharmaceutical Development & Commercialization, Inc.

Are carer attitudes toward medications related to self-reported medication adherence amongst people with mental illness?

Medication nonadherence among consumers with psychiatric disorders can significantly affect the health and wellbeing of the consumer and their family. Previous research has suggested that carers have an impact on consumer attitudes toward medication and adherence. Yet, how carer attitudes toward medication may be related to consumer attitudes and adherence has received little investigation. This exploratory study aimed to investigate the relationships between carer and consumer attitudes toward medication and consumer adherence behaviour. A cross-sectional survey assessing consumer and carer attitudes toward medication and consumer adherence was conducted amongst 42 consumer-carer dyads. Correlation analyses showed a positive association between consumer and carer attitudes toward medication and between consumer and carer attitudes with adherence. There was a general indication that the greater the difference between consumer and carer attitudes, the lower the level of adherence. Regression analyses revealed that while neither consumer nor carer attitudes were significant predictors of adherence, carer attitudes appeared to have a stronger role in adherence than consumer attitudes. These preliminary results highlight the importance of carer attitudes in relation to patient perceptions and behaviours toward medication, and thus the potential benefits of addressing both consumer and carer attitudes in any intervention for improving adherence.

Integrative Review of Mobile Phone Contacts and Medication Adherence in Severe Mental Illness

BACKGROUND

Poor medication adherence is a significant problem in individuals with severe mental illness (SMI). About 50% of people with SMI become nonadherent to treatment in the first month following discharge from the hospital.

OBJECTIVE

This study examined literature in the past decade (2006-2016) on the use of mobile phone contacts in individuals with SMI to improve medication adherence post hospital discharge.

DESIGN

This integrative review used the search terms texting, text messaging, SMS, cell/mobile phone, medication adherence, medication compliance, and mental illness. Databases (CINAHL, PubMed, PsycINFO, and Scopus) and manual searching of reference lists were done. The main inclusion criteria were the use of mobile phone contacts on medication adherence in individuals with SMI. Adults 18 years and older, studies conducted from 2006 to 2016, and studies conducted in English were also criteria for inclusion. Only five studies met criteria for inclusion.

RESULTS

Outcomes from the review showed that mobile phone contacts have been used to improve medication adherence in individuals with SMI and able to provide the four types of social support (instrumental, informational, emotional, and, appraisal). When phone contacts especially text messaging was used as an adjunct to other interventions, it yielded better medication adherence than when used alone. However, results on medication adherence rates were mixed in participants on both psychiatric and nonpsychiatric medications.

CONCLUSION

Although mobile phone contacts are a promising tool to enhance medication adherence after hospital discharge, its effectiveness to increase medication adherence in this population remains inconclusive.

Are people with schizophrenia adherent to diabetes medication? A comparative meta-analysis

Individuals living with schizophrenia are 2-3 times more likely to experience type 2 diabetes mellitus. Diabetes medication adherence is essential to reduce morbidity and mortality in this population. We conducted a meta-analysis of diabetes medication adherence among people with schizophrenia, and compared this to those without schizophrenia. A systematic search strategy was used to identify all articles reporting adherence to diabetes medications among patients with schizophrenia. In total, 10 unique studies reporting data from 33,910 people with schizophrenia were included. Random effects meta-analysis showed people with schizophrenia adhered to medication on 77.3% of days prescribed (n=32080, 95%CI=73.6-81%, I²=99.2%,), and adhered on 4.6% more days per year than those without schizophrenia (p<0.01, 95%CI=2.4-6.7%, I²=92.5%, schizophrenia n=19367, controls=170,853). Furthermore, 56% of individuals with schizophrenia (n=33680) were considered "adherent" (i.e. >80% adherence over 12-24 month) to diabetes medication, which was significantly more than those without schizophrenia (OR=1.34, 95%CI: 1.18-1.52, p<0.01). Factors which were positively associated with diabetes medication adherence were age, number of outpatient visits, along with multiple medication administration variables. Future prospective research should examine diabetes monitoring, medication prescription, and subsequent adherence in fully representative samples. Novel interventions for maximizing compliance to diabetes medication in this vulnerable population should also be explored.

Interventions to Improve Pharmacological Adherence Among Adults With Psychotic Spectrum Disorders and Bipolar Disorder: A Systematic Review

BACKGROUND

It is unclear as to which interventions are effective at improving medication adherence in individuals with serious and persistent mental illness. The goal of this systematic review is to synthesize evidence examining the effectiveness, harms, and costs of interventions to improve medication adherence in patients with psychotic spectrum disorders and bipolar disorder.

METHODS

We conducted a systematic search of several electronic databases through January 2015 using a structured search strategy. Studies were included if they involved adult patients in general mental health settings, reported both measures of medication adherence and clinical outcomes, and were of sufficient methodological rigor. Studies were quality assessed and synthesized using established methods.

RESULTS

We identified 24 studies that met inclusion criteria. Overall, 20 studies addressed interventions in patients with psychotic spectrum disorders. These interventions varied widely, with generally mixed findings contributing to low or insufficient strength of evidence; studies involving family members and technology interventions were the most consistently associated with a positive effect; however, the strength of the evidence was low because of intervention heterogeneity. The evidence was insufficient to determine the effectiveness of interventions in patients with bipolar disorder.

CONCLUSIONS

In individuals with psychotic spectrum disorders, interventions with family members or technology had the most consistent positive effect on adherence, although replication with objective adherence measures along with evaluation of harms and costs is needed. There was insufficient evidence to draw conclusions about interventions in individuals with bipolar disorder.

Adherence to Psychotropic and Nonpsychotropic Medication Among Patients With Bipolar Disorder and General Medical Conditions

OBJECTIVE

This study assessed the relationship between nonadherence to psychotropic and nonpsychotropic medications for 88 patients nonadherent to medication treatment for bipolar disorder.

METHODS

This descriptive study was part of a clinical trial promoting medication adherence. Nonadherence was defined as ≥ 20% of days with missed doses.

RESULTS

A majority of the sample was female and had type I bipolar disorder; 49% had hypertension, 39% had hyperlipidemia, and 69% smoked; average body mass index was 34, and 65% were obese. The median proportion of days with missed doses was 53.6% (interquartile ratio [IQR]=38.10%-73.40%) for psychotropic medications and 33.93% (IQR=13.81%-51.91%) for nonpsychotropic medications. There was a significant difference between nonadherence to psychotropic and nonpsychotropic medication for the past week (z=-4.11, p<.001) and past month (z=-4.19, p<.001). More global psychopathology was associated with nonpsychotropic nonadherence.

CONCLUSIONS

Psychotropic adherence was worse than nonpsychotropic adherence, yet both were poor. Improving adherence to cardiovascular medications is a reasonable pathway to improve cardiovascular health in this population.

Diabetes treatment in people with type 2 diabetes and schizophrenia: Retrospective primary care database analyses

AIMS

Aim of this study were to compare outcomes (HbA1c, BMI) and antidiabetic treatment of type 2 diabetes patients with and without schizophrenia under real-life conditions in primary care practices in Germany.

METHODS

1321 type 2 diabetes patients with and 1321 matched controls (age, sex, diabetes duration, diabetologist care, practice) without schizophrenia in 1072 general practices throughout Germany were retrospectively analyzed (Disease Analyser: 01/2009-12/2013). Antidiabetic treatment, HbA1c and BMI were compared using paired t-tests, McNemar tests and conditional logistic regression adjusting for macro- and microvascular comorbidity (ICD-10).

RESULTS

Mean age (±SD) of patients and controls was 67.4±13.2 years (males: 38.9%). Diabetes duration was 5.7±4.3 years, 6% were in diabetologist care. Private health insurance was less often found among patients with schizophrenia than controls (2.2% vs 6.3%; p<0.0001). There was no difference in the mean HbA1c values (cases: 7.1±1.4%; controls: 7.2±1.5%) (54.1 vs. 55.2 mmol/mol) (p=0.8797) and in the average BMI (32.4±6.6 vs. 31.0±5.0 kg/m(2); p=0.2072) between the two groups. Novel cost-intensive antidiabetic agents (DPP-4- or SGLT2-inhibitors, GLP-1 receptor agonists) were less often prescribed in cases (15.3 vs. 18.3%; p=0.0423). However, in multivariable logistic regression, schizophrenia (odds ratio, 95%CI: 1.101; 0.923-1.317) was not associated with prescription use of novel antidiabetic agents (reference: other antidiabetic agents) after adjusting for private health insurance (OR: 2.139; 1.441-3.177) and comorbidity.

CONCLUSIONS

There is no evidence that type 2 diabetes patients with schizophrenia have worse diabetes control than those without a severe mental illness in general practices.

Adherence to common cardiovascular medications in patients with schizophrenia vs. patients without psychiatric illness

OBJECTIVE

The purpose of the study was to examine whether individuals with diagnoses of schizophrenia were differentially adherent to their statin or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) medications compared to individuals without psychiatric illness.

METHOD

Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of schizophrenia or schizoaffective disorder receiving two or more medication dispensings of a statin or an ACEI/ARB in 2011 (N=710) were identified and matched on age, sex and Medicare status to controls with no documented mental illness and two or more medication dispensings of a statin in 2011 (N=710). Medication adherence, and sociodemographic and clinical characteristics of the study population were assessed.

RESULTS

Multivariable models indicated that having a schizophrenia diagnosis was associated with increased odds of statin medication adherence; the odds ratio suggested a small effect. After adjustment for medication regimen, schizophrenia no longer showed an association with statin adherence. Having a schizophrenia diagnosis was not associated with ACEI/ARB medication adherence.

CONCLUSIONS

Compared to patients without any psychiatric illness, individuals with schizophrenia were marginally more likely to be adherent to their statin medications. Given that patterns of adherence to cardioprotective medications may be different from patterns of adherence to antipsychotic medications, improving adherence to the former may require unique intervention strategies.

Baseline characteristics and hospitalizations in patients with schizophrenia receiving olanzapine long-acting injection: an interim analysis from a non-interventional, prospective observational safety study

BACKGROUND

Depot antipsychotics are a treatment option for medication nonadherence in patients with schizophrenia. Nonadherence can lead to increased relapse and hospitalization rates. This article reports hospitalization data before and after initiation of olanzapine long-acting injection (LAI), a depot antipsychotic.

METHODS

Data were assessed from an ongoing, multinational, prospective, observational post-authorisation safety study being conducted to evaluate post-injection delirium/sedation syndrome (PDSS), an adverse reaction that can occur following injection of olanzapine LAI. Eligible patients were aged ≥18 years, diagnosed with schizophrenia, were prescribed olanzapine LAI, and lived outside the United States. Psychiatric hospitalization and medication data were collected retrospectively for the 6-month period before study entry and prospectively throughout the study. Paired t-tests and McNemar's tests were used to assess changes in hospitalization incidence and duration. Stepwise Cox proportional hazards models assessed factors associated with hospitalizations. Analyses were based on data from the first 3 years of the continuously enrolling study (N = 668).

RESULTS

The average duration of olanzapine LAI exposure for all patients was 0.768 years. Of the 529 patients who received at least 1 injection of olanzapine LAI and were not hospitalized at study entry, 8.1% had at least 1 subsequent psychiatric hospitalization with a mean duration of 2.0 days. Of the 288 patients who had a >6-month follow-up, 8.3% had at least 1 post-baseline psychiatric hospitalization with a mean duration of 2.3 days. The incidence of hospitalizations in the 6-month period after treatment was significantly lower than that in the 6-month period prior to treatment (8.3 vs 32.6%, respectively; P < 0.001). Furthermore, mean hospitalization duration decreased from 11.5 days in the 6-month period before treatment to 2.3 days in the 6-month period after treatment (P < 0.001). Psychiatric hospitalization in the prior 12 months (P < 0.0001) and recreational drug use within 24 h of baseline visit (P = 0.015) were identified as potential predictors of time to first psychiatric hospitalization after beginning to take olanzapine LAI. At the time of interim analysis, 5 PDSS events had occurred, which was too few for a full analysis of those events.

CONCLUSIONS

Results indicate a significant reduction in the incidence and days of hospitalization from the 6-month period before to the 6-month period after olanzapine LAI initiation, which suggests reduced relapse and hospitalization during treatment. Results should be interpreted with caution due to the observational nature of the study and use of retrospective baseline data.

Strategies to improve medication adherence in patients with schizophrenia: the role of support services

The purpose of this review is to describe research over the past 10 years on the role of support services in promoting medication adherence in mental health consumers diagnosed with schizophrenia. A literature search was conducted using the terms "medication adherence," "schizophrenia," and "support services," using Medline, PubMed, and CINAHL. Reference lists from published studies were also reviewed to identify additional research studies. Twenty-two articles focused on support-service intervention studies, and these were selected for review. Available support-service interventions include adherence therapy, electronic reminders via text messages and telephones, cognitive-behavioral and motivational strategies, and financial incentives. Support-service intervention strategies need to be tailored to the specific needs of mental health consumers with schizophrenia. More research is needed to investigate effective support services to enhance long-term adherence and adherence to medications for medical illnesses in this population.

Medication adherence among older adults with schizophrenia

Older adults with schizophrenia are a growing segment of the population, yet their physical and mental health status is extremely poor. This article presents findings from a qualitative study that explored the understanding older adults with schizophrenia have of their physical health status. The study was conducted among 28 older adults with schizophrenia from a variety of settings using semi-structured interviews and participant observation. Self-management of psychiatric and non-psychiatric medications and its effect on participants' health status was one of the central themes that emerged from the study. Different styles of medication adherence were identified and factors associated with each style are presented. The findings provide insights into the design of clinical interventions aimed at promoting medication adherence among older adults with schizophrenia.

Evaluation of a Pharmacist-Managed Anticoagulation Clinic

Background

Anticoagulation therapy is important in the prevention and treatment of cardioembolic events. Warfarin is frequently used but requires continual monitoring to ensure safety and efficacy. The target time in therapeutic range (TTR) is not always achieved.

Objectives

The objectives for this study were to determine the TTR for a pharmacist-managed anticoagulation clinic and identify reasons for sub- and supratherapeutic international normalized ratio (INR) values.

Methods

Medical records for subjects prescribed warfarin were reviewed. Demographic and relevant clinical information was assessed. INR measurements were extracted for subjects enrolled. The TTR was calculated, and the cause for sub- or supratherapeutic values was determined when possible.

Results

One hundred twenty-six subjects were included in this retrospective study. The calculated TTR was 51%. The cause for more than 65% of the sub- and supratherapeutic INR values could not be determined. One subject incurred a clot and 6 subjects suffered a bleed. No deaths occurred. Age was the only factor that correlated with a supratherapeutic INR value ( r = −0.179, P = .045).

Conclusion

Pharmacists in the anticoagulation clinic are effectively managing patients who are taking warfarin by frequently maintaining INR values near or within the recommended therapeutic range. Very few negative outcomes occurred during the time of study.

Beliefs about antipsychotic versus hypoglycemic medications among individuals with serious mental illness and type 2 diabetes

BACKGROUND

This study compared the beliefs held by individuals with coexisting serious mental illness and type 2 diabetes regarding the necessity and risks of taking antipsychotic versus hypoglycemic medications. We also investigated whether nonadherent patients differed from adherent patients in their beliefs about medications.

METHODS

Forty-four individuals with type 2 diabetes and serious mental illness who were prescribed hypoglycemic and antipsychotic medications completed a cross-sectional assessment of medication beliefs and adherence for both medication types.

RESULTS

Patients perceived a greater need for hypoglycemic versus antipsychotic medications; however, their beliefs were not associated with nonadherence to either medication type.

CONCLUSION

These results suggest that individuals with coexisting serious mental illness and type 2 diabetes have stronger convictions regarding the necessity of their diabetes medication for maintaining their health.

Adesão ao tratamento medicamentoso em pacientes do espectro esquizofrênico: uma revisão sistemática da literatura

OBJETIVO: Realizar revisão sistemática para avaliar a adesão medicamentosa ao tratamento em pacientes do espectro esquizofrênico. MÉTODO: As buscas dos artigos foram conduzidas nas seguintes bases de dados: PubMed/Medline, Lilacs, SciELO e PePSIC, considerando artigos publicados entre 2001 e 2010. Na estratégia de busca, foram utilizados descritores de acordo com sua definição no DeCS e no MeSH: "schizophrenia" and "patient adherence" or "patient compliance" or "medication adherence". As correspondências em português e espanhol foram respectivamente "esquizofrenia/esquizofrenia" e "cooperação do paciente/cooperácion del paciente" ou "adesão à medicação/cumplimiento de lá medicación". Também foram realizadas buscas manuais nas referências dos artigos selecionados. RESULTADOS: A busca bibliográfica resultou em 1.692 artigos. Contudo, apenas 54 preencheram os critérios para compor esta revisão. CONCLUSÕES: A maioria dos estudos sobre o tema foi realizada em países desenvolvidos, prejudicando a aplicação dos achados à nossa realidade. As taxas da adesão e os métodos utilizados para avaliação variaram bastante, porém os fatores associados à não adesão se repetiram, como falta de insight, comorbidade com uso de substâncias psicoativas, falta de apoio social, efeitos colaterais da medicação, comportamento violento, situação de rua, tentativa de suicídio, entre outros. Assim sendo, há necessidade da realização de mais estudos nacionais para investigar potenciais variáveis associadas a não adesão e suas consequências para a população estudada.

Adherence to antihyperlipidemic medication and lipid control in diabetic Veterans Affairs patients with psychotic disorders

BACKGROUND

Medication adherence for chronic medical illnesses has been studied extensively, but there is limited data evaluating medication adherence for comorbid medical illnesses in a psychiatric population. Furthermore, only one study has evaluated both medication adherence and clinical outcomes between the two populations. Examining medication adherence rates and clinical outcomes are important as chronic medical illnesses occur commonly in psychiatric patients, can be drug-induced, and have negative long-term consequences.

OBJECTIVES

To compare antihyperlipidemic medication adherence and lipid control between individuals with psychotic disorders and those without a psychiatric illness.

METHODS

This was a retrospective medical record review of 124 subjects with hyperlipidemia and diabetes (62 subjects with schizophrenia or a related psychotic disorder and 62 randomly selected, age-matched individuals without a psychiatric illness) receiving medical and psychiatric care through the Veterans Affairs Medical Center during 2008. Cumulative mean gap ratio (CMGR) was used to determine adherence. Lipid values were utilized to compare lipid control between groups.

RESULTS

A significant difference in CMGR was detected. Subjects with psychotic disorders were without antihyperlipidemic therapy for 44 days compared with 62 days for the nonpsychiatric comparison group (P = 0.034). Antipsychotic adherent subjects (≥80% adherent) were more likely to adhere to their antihyperlipidemic medication (P = 0.0007). There were no significant differences between the groups for lipid control.

CONCLUSION

Antihyperlipidemic medication adherence differed with the psychotic disorder group having fewer days without drug therapy. However, there was no significant difference in lipid control between subjects with a psychotic disorder and those without a psychiatric illness.

Relational agents as an adjunct in schizophrenia treatment

The purpose of this article is to discuss medication nonadherence and the use of relational agent technology as an aid in treating patients with schizophrenia. A team of mental health faculty-specialists in adherence, computer science, and statistics-collaborated to design the agent technology. This computerized virtual health counselor named "Laura" provides seven education modules about schizophrenia. Using preliminary data, two individual examples demonstrate the use of this technology. Implications for behavioral health nurses using this relational agent technology as an adjunct in improving mental health care are discussed.

A comparison of adherence to hypoglycemic medications between Type 2 diabetes patients with and without serious mental illness

Inadequate self-management of chronic medical conditions like Type 2 diabetes may play a role in the poor health status of individuals with serious mental illnesses. We compared adherence to hypoglycemic medications and blood glucose control between 44 diabetes patients with a serious mental illness and 30 patients without a psychiatric illness. The two groups did not differ in their ability to manage a complex medication regimen as assessed by a performance-based measure of medication management capacity. However, significantly fewer patients with a mental illness self-reported nonadherence to their hypoglycemic regimens compared to those without a mental illness. Although individuals with mental illnesses also had better control of blood glucose, this metabolic parameter was not correlated with adherence to hypoglycemic medications in either patient group. The experience of managing a chronic mental illness may confer advantages to individuals with serious mental illnesses in the self-care of co-occurring medical conditions like Type 2 diabetes.

Medication adherence and glycemic control in patients with psychotic disorders in the Veterans Affairs healthcare system

OBJECTIVE

To compare antihyperglycemic medication adherence and glycemic control between individuals with schizophrenia and related psychotic disorders and a nonpsychiatric comparison group.

METHODS

This was a retrospective medical record review. A total of 124 subjects with diabetes (62 patients with schizophrenia or a related psychotic disorder and 62 randomly selected, age-matched patients without a psychiatric illness) receiving their medical and psychiatric care exclusively through the Kansas City Veterans Affairs healthcare system during 2008 were included in the study. Adherence to antihyperglycemic and antipsychotic medication was determined by refill records obtained through the computerized patient record system to calculate the cumulative mean gap ratio. Hemoglobin A1C values were utilized to compare glycemic control between groups and compared to glycemic goals established by diabetes treatment guidelines.

RESULTS

Antihyperglycemic medication adherence was poor for both groups as approximately 60% of the psychotic disorder group and 75% of the nonpsychiatric comparison group were without antihyperglycemic medication for greater than 30 days during the 12-month period but adherence did not differ between the groups (p=0.182). Antipsychotic adherent subjects (≥80% adherent) were more likely to be adherent to their antihyperglycemic medication (p=0.0003). There were no significant differences between groups in glycemic control.

CONCLUSIONS

Antihyperglycemic medication adherence and glycemic control was less than optimal for both groups. There were no significant differences in antihyperglycemic medication adherence and glycemic control between patients with a psychotic disorder and those without a psychiatric illness.

Physical health in schizophrenia: a challenge for antipsychotic therapy

In the management of schizophrenia, mental health outcomes are the principal focus of treatment. The objective is to control the psychotic symptoms while minimising negative features of the illness, to achieve an overall improvement in the societal functioning of patients. Physical health is also important because if it is compromised, many of the benefits of improved mental health will be offset. Compared with the general population, schizophrenia patients are at increased risk of weight gain, abdominal obesity, diabetes, metabolic syndrome, and cardiovascular disease. These physical health problems can contribute to the decreased quality of life, lowered self-esteem and reduced life expectancy commonly reported in schizophrenia. For these reasons there is a pressing need to improve both the monitoring and the management of physical health in patients with schizophrenia as a part of their overall care. A consensus for metabolic monitoring of patients receiving treatment with antipsychotic drugs is available. However, the practicing clinician requires guidance about management of physical health in routine clinical practice. This should include recommendations for measurements that have strong predictive value about physical health risks yet are easy to make, and about the use of medications that have the least effect on physical health parameters. This article will review the gravity of the physical health risks facing schizophrenia patients.

Psychotropic medication adherence in correctional facilities: a review of the literature

Despite the high percentage of incarcerated persons with mental illness, surprisingly little is known about effective ways to increase psychotropic medication adherence in prison and upon release. Currently, there are limited definitive data regarding psychotropic medication adherence patterns among incarcerated persons, and the data that exist often miss specific information on changes in behaviour, symptom management and adherence patterns over the length of a person's sentence, which has implications for post-release ability to live in the community. This paper presents the current literature regarding psychotropic medication adherence among mentally ill persons who are incarcerated. The factors identified in support of medication adherence, future clinical research and care strategies are provided.

Does adherence to medications for type 2 diabetes differ between individuals with vs without schizophrenia?

Individuals with schizophrenia are at increased risk for poor health outcomes and mortality. This may be due to inadequate self-management of co-occurring conditions, such as type 2 diabetes. We compared adherence to oral hypoglycemic medications for diabetes patients with vs without comorbid schizophrenia. Using Veterans Affairs (VA) health system administrative data, we identified all patients with both schizophrenia and type 2 diabetes and with at least one oral hypoglycemic prescription fill in fiscal year 2002 (N = 11 454) and a comparison group of patients with diabetes who were not diagnosed with schizophrenia (N = 10 560). Nonadherence was operationalized as having a medication possession ratio indicating receipt of less than 80% of needed hypoglycemic medications. Poor adherence was less prevalent among diabetes patients with (43%) than without schizophrenia (52%, P < .001). In multivariable analyses, having schizophrenia was associated with a 25% lower likelihood of poor adherence compared with not having schizophrenia (adjusted odds ratio: 0.75, 95% confidence interval: 0.70-0.80). Poorer adherence was associated with black race, homelessness, depression, substance use disorder, and medical comorbidity. Having more outpatient visits, a higher proportion of prescriptions delivered by mail, lower prescription copayments, and more complex medication regimens were each associated with increased adherence. Among veterans with diabetes receiving ongoing VA care, overall hypoglycemic medication adherence was low, but individuals with comorbid schizophrenia were more likely to be adherent to these medications. Future studies should investigate whether factors such as comanagement of a chronic psychiatric illness or regular contact with mental health providers bestow benefits for diabetes self-management in persons with schizophrenia.

Differences in adherence to antihypertensive medication regimens according to psychiatric diagnosis: results of a Korean population-based study

OBJECTIVE

To identify the relationship between various types of psychiatric disorders and adherence to antihypertensive medication.

METHODS

We obtained data from claims submitted to the National Health Insurance, which covers almost the entire Korean population. Of the total of 2,454,844 patients who received prescriptions for antihypertensive medication during 2004, the study used data from 158,982 patients diagnosed with psychiatric disorders and 2,295,862 patients without psychiatric disorders according to International Classification of Diseases 10th Revision. We measured cumulative medication adherence (CMA) and compared the rates of appropriate level of adherence, defined as CMA > or =80%, between individuals with and without psychiatric disorders. We used multiple logistic regression to identify differences in antihypertensive medication adherence according to the type of psychiatric disorder.

RESULTS

Adherence to antihypertensive medication regimens was lower among patients with dementia, alcohol use disorders, psychotic disorders, and mood disorders-accounting for 15.4% of the patients with psychiatric disorders. On the other hand, the majority of patients (82.8%) who had substance use disorders, anxiety disorders, neurotic and somatoform disorders, and behavioral syndromes showed greater adherence. Overall adherence was higher in those with psychiatric disorders than in those without psychiatric disorders after adjusting for sociodemographic and clinical factors (odds ratio = 1.03, 95% Confidence Interval = 1.02-1.04).

CONCLUSIONS

Adherence to medication is reduced in patients with various types of psychiatric disorders, usually those accompanied by functional impairment. Effective strategies for improving medication adherence should be tailored to individual levels of function and psychopathology.

Cure or curse? Ambivalent attitudes towards neuroleptic medication in schizophrenia and non-schizophrenia patients

Neuroleptic non-compliance remains a serious challenge for the treatment of psychosis. Non-compliance is predominantly attributed to side effects, lack of illness insight, reduced well-being or poor therapeutic alliance. However, other still neglected factors may also play a role. Further, little is known about whether psychiatric patients without psychosis who are increasingly prescribed neuroleptics differ in terms of medication compliance or about reasons for non-compliance by psychosis patients. As direct questioning is notoriously prone to social desirability biases, we conducted an anonymous survey. After a strict selection process blind to results, 95 psychiatric patients were retained for the final analyses (69 participants with a presumed diagnosis of schizophrenia psychosis, 26 without psychosis). Self-reported neuroleptic non-compliance was more prevalent in psychosis patients than non-psychosis patients. Apart from side effects and illness insight, main reasons for non-compliance in both groups were forgetfulness, distrust in therapist, and no subjective need for treatment. Other notable reasons were stigma and advice of relatives/acquaintances against neuroleptic medication. Gain from illness was a reason for non-compliance in 11-18% of the psychosis patients. Only 9% of all patients reported no side effects and full compliance and at the same time acknowledged that neuroleptics worked well for them. While pills were preferred over depot injections by the majority of patients, depot was judged as an alternative by a substantial subgroup. Although many patients acknowledge the need and benefits of neuroleptic medication, non-compliance was the norm rather than the exception in our samples.

Adherence to antipsychotics among Latinos and Asians with schizophrenia and limited English proficiency

OBJECTIVES

The authors examined data for 7,784 Latino, Asian, and non-Latino white Medi-Cal beneficiaries with schizophrenia to determine the relationship between patients' preferred language for mental health services--English, Spanish, or an Asian language--and their adherence to treatment with antipsychotic medications.

METHODS

Data reflected 31,560 person-years from 1999 to 2004. Pharmacy records were analyzed to assess medication adherence by use of the medication possession ratio (MPR). Clients were defined as nonadherent (MPR<.5), partially adherent (MPR=.5-<.8), or adherent (MPR=.8-1.1) or as an excess filler of prescriptions (MPR<1.1). Regression models were used to examine adherence, hospitalization, and costs by race-ethnicity and language status.

RESULTS

Latinos with limited English proficiency were more likely than English-proficient Latinos to be medication adherent (41% versus 36%; p<.001) and less likely to be excess fillers (15% versus 20%; p<.001). Asians with limited English proficiency were less likely than English-proficient Asians to be adherent (40% versus 45%; p=.034), more likely to be nonadherent (29% versus 22%; p<.001), and less likely to be excess fillers (13% versus 17%; p=.004). When analyses controlled for adherence and comorbidities, clients with limited English proficiency had lower rates of hospitalization and lower health care costs than English-proficient and white clients.

CONCLUSIONS

Adherence to antipsychotic medications varied by English proficiency among and within ethnic groups. Policies supporting the training of bilingual and multicultural providers from ethnic minority groups and interventions that capitalize on patients' existing social support networks may improve adherence to treatment in linguistically diverse populations.

Telenursing intervention increases psychiatric medication adherence in schizophrenia outpatients

BACKGROUND

Promoting medication adherence is a critical issue in optimizing both physical and mental health in persons with schizophrenia. Average antipsychotic medication adherence is only 50%; few studies have examined nonpsychiatric medication adherence. Psychosocial interventions with components of problem solving and motivation have shown promise in improving adherence behaviors.

OBJECTIVES

This study examines telephone intervention problem solving (TIPS) for outpatients with schizophrenia. TIPS is a weekly, provider-initiated, proactive telenursing intervention designed to help persons with schizophrenia respond to a variety of problems, including adherence problems.

STUDY DESIGN

The authors completed objective measures of adherence to psychiatric and nonpsychiatric medications in 29 community-dwelling persons with schizophrenia, monthly for 3 months.

STUDY RESULTS

Persons receiving TIPS had significantly higher objective adherence to psychiatric medications throughout the study period, F(1, 20) = 5.47, p = .0298.

CONCLUSIONS

Clinicians should consider using TIPS as an adjunct to face-to-face appointments to support adherence in persons at risk. J Am Psychiatr Nurses Assoc, 2008; 14(3), 217-224. DOI: 10.1177/1078390308318750.

Evaluation of the feasibility of switching from immediate release quetiapine to extended release quetiapine fumarate in stable outpatients with schizophrenia

This double-blind, double-dummy study (D1444C00146) evaluated the efficacy and safety of switching patients with clinically stable schizophrenia from quetiapine immediate release (IR) to the same dose of once-daily extended release quetiapine fumarate (quetiapine XR). Patients received quetiapine IR 400-800 mg/day twice daily for 4 weeks, and were then randomized (2 : 1) to a once-daily equivalent dose of quetiapine XR or maintained on IR for 6 weeks. The primary variable was the proportion of patients who discontinued treatment owing to lack of efficacy or whose Positive and Negative Syndrome Scale scores increased by at least 20% from randomization to any visit. In total, 497 patients were randomized to quetiapine XR (n=331) or IR (n=166). Noninferiority (6% margin; one-sided test, 2.5% significance level) was narrowly missed for the primary efficacy variable for the modified intention-to-treat population (9.1%, quetiapine XR; 7.2%, quetiapine IR; difference 1.86%; 95% confidence interval: -3.78, 6.57; P=0.0431), but was shown for the per-protocol population (5.3%, quetiapine XR; 6.2%, quetiapine IR; difference: -0.83%; 95% confidence interval: -6.75, 3.71; P=0.0017). Serious adverse event incidence was low for quetiapine XR and IR; there were no unexpected adverse events. In conclusion, efficacy was maintained without compromising safety/tolerability when switching patients with stable schizophrenia from twice-daily quetiapine IR to once-daily quetiapine XR (400-800 mg/day).

No health without mental health

About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. Such estimates have drawn attention to the importance of mental disorders for public health. However, because they stress the separate contributions of mental and physical disorders to disability and mortality, they might have entrenched the alienation of mental health from mainstream efforts to improve health and reduce poverty. The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury. Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis. Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved. We need to develop and evaluate psychosocial interventions that can be integrated into management of communicable and non-communicable diseases. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programmes and activities, such as those which address the prevention and treatment of HIV, tuberculosis, and malaria; gender-based violence; antenatal care; integrated management of childhood illnesses and child nutrition; and innovative management of chronic disease. An explicit mental health budget might need to be allocated for such activities. Mental health affects progress towards the achievement of several Millennium Development Goals, such as promotion of gender equality and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV/AIDS. Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care.

Exercise interventions as an adjunct therapy for psychosis: a critical review

PURPOSE

To review the existing evidence examining effectiveness of exercise as an adjunct therapy for psychosis.

METHOD

A search of databases including Pub Med, Psych Info, Cochrane Library, Cinahl, Sports Discus and Web of Knowledge was conducted to identify studies investigating the psychological changes following exercise interventions in people with psychosis. Literature was subjected to a critical review to determine the effectiveness of exercise as a therapy for psychosis.

RESULTS

A total of ten studies met the inclusion criteria: four quantitative, two qualitative and four using a mixed method design. Exercise interventions were supervised and generally lasted between 10 and 12 weeks. Study samples were small, even in the quantitative studies, meaning that statistical analysis was not always possible. Study design and outcome measures varied across all studies. Generally the research findings demonstrated a positive trend towards improved mental health for those participants utilising exercise.

CONCLUSION

The findings suggest the presence of a positive effect of exercise on mental health in people with psychosis, yet there is a need for greater consistency within the research to determine the size of effects and the most successful type of intervention. As exercise is increasingly used in the mental health service, more research is needed to provide a more comprehensive evidence-based practice.

Pulmonary disease among inpatient decedents: Impact of schizophrenia

OBJECTIVES

Determine the risk associated with schizophrenia for common pulmonary illness (pneumonia and chronic obstructive pulmonary disorder (COPD)) during the last year of life.

METHODS

Inpatient decedents in Veterans (VA) hospitals in 2002 (N=27,798) were identified. Logistic regression modeled diagnosis of pulmonary illness in either the final year or final admission as a function of schizophrenia, smoking history and other covariates.

RESULTS

Among decedents, 943 (3%) had schizophrenia, 3% were women, most were white (76%) or African-American (18%), and average age at death was 72.4 years (SD 11.5). Three-fifths received VA outpatient care in the year prior to death. Among those with schizophrenia, only two-fifths had outpatient care. Pneumonia was more common among schizophrenia patients (38% vs 31%) as was COPD (46% vs 38%). In models controlling for history of smoking and other covariates, schizophrenia was a risk factor for pulmonary disease in the last year of life (OR=1.9, 95% CI 1.6-2.2) but less so for final-stay pulmonary disease (OR=1.5, 95% CI 1.3-1.7).

CONCLUSIONS

VA inpatient decedents with schizophrenia were at increased risk for pneumonia and COPD, independent of smoking indicators. Clinicians treating schizophrenia patients need to be especially alert to potential comorbid medical conditions and ensure vulnerable patients receive appropriate care.

The relationship of antipsychotic medication class and adherence with treatment outcomes and costs for Florida Medicaid beneficiaries with schizophrenia

While some studies show a significant advantage in adherence rates with use of atypical versus typical antipsychotic medication, others show no advantage or mixed results (Jones et al. (2006). Archives of General Psychiatry, 63, 1079-1087; Rosenheck, (2006). Archives of General Psychiatry, 63, 1074-1076). This study examined treatment outcomes and costs associated with adherence rates by antipsychotic medication class for adult Medicaid beneficiaries in Florida diagnosed with schizophrenia. Outcomes examined include arrests, involuntary commitments, and physical and behavioral healthcare costs. Study findings demonstrate that medication adherence for persons with schizophrenia may be as important to treatment costs and benefits as the class of medication used.

Cognitive and psychiatric predictors of medical treatment adherence among older adults in primary care clinics

OBJECTIVES

Medical treatment non-adherence among older adults is common and represents a significant public health care concern. Treatment non-adherence has been associated with a number of factors in older adults; however few studies have delineated the role of cognition and psychiatric status.

PARTICIPANTS

Data were collected from 212 ethnically diverse older primary care patients as part of a larger study.

MEASUREMENTS

Cognitive status was evaluated with the Mattis Dementia Rating scale (DRS). Psychiatric status was evaluated using the Geriatric Depression Scale (GDS) and the Beck Anxiety Inventory (BAI). Treatment adherence was assessed by the total number of missed healthcare appointments and by physician and patient ratings. Physician ratings of patients' understanding of medical instructions were also obtained.

DESIGN

A series of multiple regression analyses were conducted to determine cognitive and psychiatric predictors for each measure of treatment adherence.

RESULTS

GDS and DRS memory scores were both independent predictors of the total number of missed medical appointments, F(7,55) = 2.34, p = 0.038. GDS score was also shown to be a significant predictor of physician ratings of patients' understanding of medical instructions, F(7,33) = 0.89, p = 0.031. Neither cognitive performance nor psychiatric status was associated with patient or physician ratings of treatment adherence.

CONCLUSIONS

Measures of cognitive functioning and depression severity were supported as predictors of objective measures of treatment adherence but they were not associated with physician or patient ratings of adherence. Patient depression may influence physician ratings of patients' comprehension of medical instructions.

Are we treating schizophrenia effectively? Understanding the primary outcomes of the CATIE study

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study for schizophrenia was designed to independently evaluate the effectiveness of antipsychotic treatment in "real-world" patients. To assess the effectiveness of the conventional antipsychotics compared to the atypicals as well as the differences among the atypicals, patients were randomized to one of four atypical antipsychotics (olanzapine, quetiapine, risperidone, ziprasidone) or a representative conventional antipsychotic (perphenazine). Effectiveness was defined by time to discontinuation and duration of successful treatment. Time to "all-cause" discontinuation reflects both efficacy (ability of a drug to reduce symptoms) and safety/tolerability. Phase I revealed discontinuation rates ranging from 64% for olanzapine to 82% for quetiapine. Differences among the medications may be important in the selection of a drug for a particular patient. Physicians should involve the patient in choosing their medication by inquiring about the patient's past experience with medications and side effects, educating the patient on the risk-benefit ratio, and considering the patient's preference. To demonstrate how results of the CATIE study can contribute to the knowledge of practicing clinicians, this monograph presents a representative clinical case patient and illustrates how the CATIE safety and efficacy data has important implications for the patient.

Medication nonadherence in older people with serious mental illness: prevalence and correlates

Medication nonadherence in people with schizophrenia and other serious mental illnesses (SMI) is multidetermined and has been consistently associated with relapse and rehospitalization, but little is known about the prevalence and correlates of nonadherence in older people with SMI. This study evaluated the interrelationships between different measures of medication adherence (including pill counts, self-report, informant report, and attitudes toward medications), and their associations with demographic characteristics, and clinical, functional, skill, and cognitive measures in a group of 72 older people with SMI living in the community. Pill counts of adherence to psychotropic medications were highly correlated with pill counts for nonpsychiatric medications. However, pill counts were weakly correlated with self-report and informant ratings, which tended to overestimate adherence. Lower medication adherence was associated with: mood disorder (compared to schizophrenia), lack of supervision, fewer prescription medications, less insight, more severe negative symptoms, and worse community functioning. Among individuals with little or no supervision of their medications, higher adherence was related to better performance on the Medication Management Administration Assessment (MMAA) role-play, which was highly correlated with several domains of cognitive functioning, suggesting that the MMAA may be a more ecologically valid measure of cognitive functioning related to medication adherence. This study highlights the importance of using multiple measures for the assessment of medication adherence in older people with SMI, including pill counts, and suggests that interventions are needed to improve adherence in this population.

Antihypertensive Medication Adherence and Blood Pressure Control in Patients With Psychotic Disorders Compared to Persons Without Psychiatric Illness

The authors compared antihypertensive medication adherence and blood pressure control among middle-aged and older outpatients with schizophrenia and related those with psychotic disorders versus persons without any psychiatric illness. A total of 178 subjects were included in the investigation (89 patients with a psychotic disorder and 89 randomly selected, age-matched comparison subjects). Although the two groups had similar antihypertensive medication adherence, the patients with a psychotic disorder were significantly less likely to have had controlled blood pressure during the 1-year study period. The results highlight the need for clinicians to monitor closely the management of medical comorbidity in patients with schizophrenia and related disorders.

Brief evaluation of medication influences and beliefs: development and testing of a brief scale for medication adherence

PURPOSE

The purpose of this study was to develop and test a brief scale (Brief Evaluation of Medication Influences and Beliefs [BEMIB]) designed to identify patients who are more likely to be nonadherent to their antipsychotic medication.

METHODS

Sixty-three outpatients with schizophrenia and related psychotic disorders were enrolled and given an assessment battery including the BEMIB, a previously published adherence scale, extrapyramidal symptom rating scales, and an adherence assessment with patient self-report and prescription refill records. The BEMIB consisted of 8 statements derived from the health belief model with a 5-point Likert-type scale for each statement. Subjects chose a single answer for each item depending on their level of agreement or disagreement.

RESULTS

According to refill records, subjects meeting BEMIB-based criteria for nonadherence had significantly larger gaps in antipsychotic therapy (greater nonadherence) compared with those of participants not meeting criteria for nonadherence. For the 1-week test-retest reliability, the BEMIB total score and 5 of 8 single items correlated significantly. BEMIB total scores correlated significantly with an established assessment of adherence (Drug Attitude Inventory), demonstrating adequate construct validity.

CONCLUSION

The BEMIB represents a promising scale for identifying patients more likely to be nonadherent to their medications.

Schizophrenia, the metabolic syndrome and diabetes

The prevalence of diabetes is increased in patients with schizophrenia. Although many reasons, including hereditary and lifestyle factors, contribute to this association, recently there has been heightened interest in the subject because of the link between the use of the newer atypical anti-psychotic drugs and the development of diabetes. These drugs cause significant weight gain and this may be one of the mechanisms by which they increase incident diabetes. The increased prevalence of diabetes among people with schizophrenia has implications for the delivery of care by psychiatrists, diabetologists and primary care.