Compliance with therapeutic regimens: a follow-up study for patients with affective disorders

A study of the prescribing of psychotropic drugs in a Dublin psychiatric hospital

To date there has been no study of prescribing habits in a psychiatric hospital in Ireland, as has happened elsewhere.

In a survey over one weekend at St. Brendan's Hospital, the prescription sheets and case notes of all 772 patients were examined.

The principal findings were polypharmacy, the use of benzodiazepines for disturbingly long periods of time, the preponderant prescription of drugs by their proprietary names and the extensive use of neuroleptics for apparently non-psychotic conditions. These results are discussed in the light of other similar surveys.

Effects of an educational compliance enhancement programme and therapeutic drug monitoring on treatment adherence in depressed patients managed by general practitioners

Medication non-adherence is a major obstacle in the treatment of affective disorders. The primary objective of this study was to evaluate two different interventions to improve adherence to antidepressant drugs. Secondary objectives included response to treatment, relation between adherence and response, patient satisfaction and tolerability. A randomized controlled design was used to assess the effect of a patient educational compliance enhancing programme (CP) and therapeutic drug monitoring in 1031 major depressed patients treated with sertraline for 24 weeks and managed by their general practitioner. Adherence was measured by questioning, measurable serum levels of sertraline and desmethylsertraline, appointments kept and a composite index including all three methods. Treatment adherence was found in 37-70% of patients, depending on the method used. Neither of the interventions resulted in a significant increase in adherence rate. However, significantly more patients in the CP group had responded at week 24 compared to patients in the control group. Overall, significantly more adherent patients responded to treatment compared to non-adherent patients, regardless of method used to determine adherence. This large study demonstrates that treatment response increases when using an educational compliance programme and that a strong relationship between treatment adherence and response exists.

Patient adherence in the treatment of depression

BACKGROUND

Non-adherence with antidepressant treatment is very common. Increasing adherence to pharmacological treatment may affect response rate.

AIMS

To review and summarise quantitative evidence on factors associated with adherence and of adherence-enhancing interventions.

METHOD

A systematic review of computerised databases was carried out to identify quantitative studies of adherence in depression. Papers retained addressed unipolar depression and considered adherence as the primary end-point.

RESULTS

Of studies published between 1973 and 1999, 32 met the review criteria: epidemiological descriptive studies (n=14): non-random comparisons of control and intervention groups (n=3); randomised interventions (n=14); and meta-analysis (n=1). Patient education and medication clinics were the interventions most commonly tested, combined with a variety of other interventions.

CONCLUSIONS

The studies did not give consistent indications of which interventions may be effective. Carefully designed clinical trials are needed to clarify the effect of single and combined interventions.

Evaluation of an instructional program for improving medication compliance for chronically mentally ill outpatients

Outpatient medication adherence is a major problem, especially for patients repeatedly hospitalized for psychiatric disorders. This study included 39 such patients who were receiving case management services from a community mental health center. Patients were matched and randomly assigned to receive in a single session either (1) information regarding medication and its benefits, (2) guidelines for assuring adherence which encompassed all phases related to pill-taking including filling prescriptions, use of a pill container, transportation, self-reminders, doctor's appointments and so forth, or (3) the same guidelines as (2) above but given in the presence of a family member who was enlisted in support. The results showed that adherence increased to about 94% after the guidelines were given for both the individual and family guideline procedure, whereas adherence remained unchanged at 73% after the medication information procedure. These results suggest a practical means for assuring a high level of medication adherence for patients with psychiatric disorders.

Effectiveness of interventions to improve patient compliance: a meta-analysis

OBJECTIVES

This article summarizes the results of 153 studies published between 1977 and 1994 that evaluated the effectiveness of interventions to improve patient compliance with medical regimens.

METHODS

The compliance interventions were classified by theoretical focus into educational, behavioral, and affective categories within which specific intervention strategies were further distinguished. The compliance indicators broadly represent five classes of compliance-related assessments: (1) health outcomes (eg, blood pressure and hospitalization), (2) direct indicators (eg, urine and blood tracers and weight change), (3) indirect indicators (eg, pill count and refill records), (4) subjective report (eg, patients' or others' reports), and (5) utilization (appointment making and keeping and use of preventive services). An effect size (ES) r, defined as Fisher's Z transformation of the Pearson correlation coefficient, representing the association between each intervention (intervention versus control) and compliance measure was calculated. Both an unweighted and weighted r were calculated because of large sample size variation, and a combined probability across studies was calculated.

RESULTS

The interventions produced significant effects for all the compliance indicators (combined Z values more than 5 and less than 32), with the magnitude of effects ranging from small to large. The largest effects (unweighted) were evident for refill records and pill counts and in blood/urine and weight change studies. Although smaller in magnitude, compliance effects were evident for improved health outcomes and utilization. Chronic disease patients, including those with diabetes and hypertension, as well as cancer patients and those with mental health problems especially benefited from interventions.

CONCLUSIONS

No single strategy or programmatic focus showed any clear advantage compared with another. Comprehensive interventions combining cognitive, behavioral, and affective components were more effective than single-focus interventions.

Patient self-administration of medication: a review of the literature

The purpose of this review was to critically examine the literature published in the English language (1983-1995) related to the use of self-medication programmes by hospital patients and to determine whether such a scheme could be implemented and evaluated within the acute medical setting. Searches revealed a wealth of information relating to self-medication and it was evident that such schemes have been welcomed with enthusiasm by clinical nurses. However, only 12 empirical studies evaluating the advantages and disadvantages of self-medication programmes could be located. The remainder were all anecdotal or described the process of implementation in such broad terms that they could not be considered to fulfil the rigorous requirements demanded of research studies. Even the 12 empirical studies contained serious methodological flaws. Thus authors' claims that self-medication increased compliance with the drug regime could not be accepted with confidence. Nevertheless, the authors made a number of sensible recommendations which logically would be expected to increase compliance. These included simplification of the drug regime and careful patient assessment with the programme tailored to meet individual need. It was also possible to highlight areas where future research could be conducted (e.g. more detailed examination of the importance nurse-patient interaction to the success of self-medication, longer-term evaluation) and to identify means of improving research designs so that this important field of patient care may in future be examined with greater rigour.

Judgment processes for medication acceptance: self-reports and configural information use

In the present study college student (N = 186) made judgments of the likelihood of accepting a medication for treatment of a hypothetically experienced clinical depression. Three types of information were manipulated: effectiveness of the medication for alleviating the symptoms of depression, potential side effects of the medication, and severity of depression hypothetically being experienced. The functional-measurement approach was used to examine whether self-reports are related to judgments and whether there is configurality in judging likelihood of medication acceptance. The results showed that subjects who reported different variables to be most important had predictably different effects of the variables in their judgments. There was also evidence for configural combination of information, and the nature of the configurality differed between subjects who reported Depression versus Side Effects as the most important type of information, respectively. The results show how the same information can be used differently by different individuals in making judgments, and that self-reports may reveal some important aspects of how information is used. The implications of the individual differences for health care consumer decision making and health care professionals' assessments and interventions are discussed.

Predictors of outcome in prophylactic lithium treatment: a 2-year prospective study

The purpose of this study of 133 affective disorder patients consecutively referred to start prophylactic lithium treatment was to identify informative predictors of outcome. Non-adherence to treatment was mainly predicted by substance abuse and many earlier admissions. Non-response among the 78 patients adhering to lithium treatment was mainly predicted by female sex, young age and previously chronic course. The overall response rate was rather poor and an excess mortality rate was found. It is suggested that patients with substance abuse should not be offered prophylactic lithium treatment unless intensive control and support is practicable, and patients with a chronic course need a more effective treatment than lithium can offer.

Quality Assurance

The QA process is recommended to anyone seeking to upgrade patient care delivery. It clarifies theories and gives substance to progressive ideas being considered for adoption. Certainly it tends to prevent premature and ill-conceived presentations. When an action is instituted, QA provides the framework that can be used to facilitate the change. As an afterthought, but as a welcome benefit, QA can foster teamwork and camaraderie among staff who assist in problem solving or bringing an idea to fruition.