Factors associated with noncompliance with psychiatric outpatient visits

Comparative effectiveness of non-pharmacological interventions on sleep in individuals with chronic musculoskeletal pain: A systematic review with network meta-analysis

This network meta-analysis aimed to estimate the comparative effectiveness of non-pharmacological interventions on sleep in individuals with chronic musculoskeletal pain. Seven databases were systematically searched up to February 2023. A random-effects network meta-analysis in a frequentist framework was performed to synthesize continuous data as standardized mean differences (SMD) along with a 95% confidence interval (95% CI). A total of 15,641 records were identified, and 107 randomized controlled trials involving 8,121 participants were included. Of 14 identified interventions, eight were significantly more effective than passive control in improving sleep quality at immediate post-intervention (SMDs = 0.67-0.74), with cognitive behavioral therapy (CBT) being the most effective treatment (SMD = 0.74, 95% CI: 0.45-1.03). Only CBT demonstrated sustained effects at short-term (SMD = 1.56; 95% CI: 0.62-2.49) and mid-term (SMD = 1.23; 95% CI: 0.44-2.03) follow-ups. Furthermore, CBT significantly improved subjective (SMD = 0.64; 95% CI: 0.25-1.03) and objective (SMD = 0.30; 95% CI: 0.01-0.59) sleep efficiency compared with passive control at immediate post-intervention. Our findings support CBT as the first-line treatment for improving sleep in individuals with chronic musculoskeletal pain, given its superior effectiveness across multiple sleep outcomes and its sustainable effects until mid-term follow-up. However, the certainty of evidence for these interventions in improving sleep quality was very low to low.

Construction of a Nomogram predictive model for post-discharge psychosomatic review of psychiatric liaison consultation patients based on medical record data

Epidemiological studies have shown that almost all physical illnesses coexist with psychiatric disorders or psychological problems, and the severity of mental illness is positively correlated with the duration and severity of physical illness. Liaison consultations are valuable in identifying and treating psychiatric disorders, but the rate of psychiatric follow-up after consultation is low in outpatients. This study aimed to investigate the factors influencing post-discharge psychosomatic follow-up visits in patients undergoing psychiatric liaison consultation in general hospitals and construct a Nomogram prediction model for patients' post-discharge psychosomatic follow-up visits. Medical record data of inpatients who received psychiatric liaison consultations at Xi'an International Medical Center Hospital in China from September 2019 to September 2020 were analyzed. Lasso regression and multivariate logistic regression analyses were conducted to screen independent influences on the occurrence of post-discharge psychosomatic follow-ups in patients undergoing psychiatric liaison consultations. Risk prediction column line graphs were constructed using R software, and the models were evaluated. Of the 494 inpatients who received psychiatric liaison consultations, 115 patients (23.279%) (mean age = 54.8 years) went for post-discharge psychosomatic follow-up, while 379 patients (mean age = 59.3 years) had no record of psychosomatic follow-up. Furthermore, occupation, interval.time, diagnosis, out.antipsychotics, and recommendations.followup were independent factors influencing post-discharge psychosomatic follow-up. The model accurately predicted post-discharge psychosomatic follow-up behavior of inpatients who received psychiatric liaison consultations. Lastly, the clinical decision curve analysis showed that the model had good validity for clinical application. Patients who received a psychiatric liaison consultation with a ≤ 10-day interval between admission to the hospital and application for consultation, were discharged with prescribed medication, and had a clear written medical order for a follow-up consultation had an increased probability of psychosomatic follow-up after discharge.

Lived Experiences of Persons with Chronic Schizophrenia Living in the Community

Background

Each individual with schizophrenia experiences life uniquely, despite the sameness in their diagnosis. Understanding their experiences is vital for their better community integration and social work practice.

Method

We used the interpretative phenomenological approach. Persons with schizophrenia seeking outpatient services at a tertiary care institute in Bengaluru, India, were recruited through purposive sampling. In-depth interviews were conducted with six participants.

Results

Some of the meta-themes and subthemes identified were as follows: (a) perception about self (struggling with the sense of self, desire for normalcy, wanting to be in control of self and desire to live independently), (b) relationship with others (feeling supported by others and feeling rejected by others), (c) coping with consequences of illness (coping with disruptions in personal life and coping with disruptions in family life), and (d) experience of seeking treatment (reasons for seeking treatment, being on medication, and behavior of mental health professionals). The participants tried to find meaning in their lives by making sense of their illness. Family and community can have a significant impact on how persons with schizophrenia perceive their lives.

Conclusion

Mental health professionals need to encourage persons' and their families' greater participation in treatment planning and clinical interventions, which will enhance persons integration within the community and will help decrease the feeling of isolation commonly experienced when one lives with chronic mental illnesses.

Dropout Rates in Psychosocial Interventions for People With Both Severe Mental Illness and Substance Misuse: A Systematic Review and Meta-Analysis

INTRODUCTION

Over the years, many psychosocial interventions for individual having both a psychotic spectrum disorder and a substance use disorder diagnoses have been developed and studied. However, there is a high dropout rate among this clinical population.

OBJECTIVES

This meta-analysis aims to replicate a previous meta-analysis on the effects of psychosocial treatment for dual disorders, while including and determining the dropout rates in those type of interventions.

METHOD

Based on a Cochrane systematic review conducted in 2019, we conducted a meta-analysis including 40 randomized clinical trials on psychosocial treatment among persons suffering from schizophrenia spectrum disorder and substance use disorder.

RESULTS

A dropout rate of 27,2% was obtained. Stimulants use significantly affected dropout rates. Age, gender, diagnosis, alcohol and cannabis abuse, and duration of treatment did not affect dropout rates.

CONCLUSION

The 27,2% rate of dropout from psychosocial treatment highlights the need to engage participants having a dual diagnosis from the start by focusing on therapeutic alliance and motivation for treatment.

Patterns of care and dropout rates from outpatient mental healthcare in low-, middle- and high-income countries from the World Health Organization's World Mental Health Survey Initiative

BACKGROUND

There is a substantial proportion of patients who drop out of treatment before they receive minimally adequate care. They tend to have worse health outcomes than those who complete treatment. Our main goal is to describe the frequency and determinants of dropout from treatment for mental disorders in low-, middle-, and high-income countries.

METHODS

Respondents from 13 low- or middle-income countries (N = 60 224) and 15 in high-income countries (N = 77 303) were screened for mental and substance use disorders. Cross-tabulations were used to examine the distribution of treatment and dropout rates for those who screened positive. The timing of dropout was examined using Kaplan-Meier curves. Predictors of dropout were examined with survival analysis using a logistic link function.

RESULTS

Dropout rates are high, both in high-income (30%) and low/middle-income (45%) countries. Dropout mostly occurs during the first two visits. It is higher in general medical rather than in specialist settings (nearly 60% v. 20% in lower income settings). It is also higher for mild and moderate than for severe presentations. The lack of financial protection for mental health services is associated with overall increased dropout from care.

CONCLUSIONS

Extending financial protection and coverage for mental disorders may reduce dropout. Efficiency can be improved by managing the milder clinical presentations at the entry point to the mental health system, providing adequate training, support and specialist supervision for non-specialists, and streamlining referral to psychiatrists for more severe cases.

Clinical features associated with early drop-out among outpatients with unipolar and bipolar depression

Drop-out from follow-up visits carries significant burden for people diagnosed with depression. The present study assesses multiple clinical moderators of drop-out among depressed outpatients. We retrospectively followed-up 131 outpatients over 6 months: 78 major depressive disorder (MDD), and 53 bipolar disorder (BD-I = 24; BD-II = 29) patients diagnosed according to the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition. Participants were assessed with standard rating scales administered by experienced psychiatrists. Upon descriptive and Cox regression analyses, 17/53 BDs (32%) dropped-out; the overall survival time until drop-out was 57.94 ± 17.79 days. BD drop-outs were younger, had an earlier age at onset, shorter illness duration, lower rates of lifetime obsessive-compulsive disorder/suicidal behavior, higher rates of substance use disorder (SUD), anxious and mixed features of depression compared to BDs attending up to six months. Among MDD patients, 10/78 cases (13%) dropped-out by month-6 with an average survival of 42.40 ± 16.45 days. Earlier age of onset, younger age, positive family history for mood disorders, lower rates of lifetime generalized anxiety disorder were significantly more frequent among drop-outs than completers, as opposite to SUD, and lifetime recurrent depression. Older age predicted lower drop-out among BDs and MDDs, although with almost null hazard ratio (HR) = 0.928, p < 0.01 vs. HR = 0.941, p < 0.01, respectively. Higher rates of lifetime SUD predicted higher drop-out rates by month-6 among MDDs (HR = 5.477, p = 0.02). Limitations of the study: retrospective design, small sample size, lack of objective measures of treatment-adherence/mood rating during follow-up. Drop-out is common in the real-world setting, warranting specific interventions since the beginning of the treatment.

Factors associated with dropout from treatment: An exploratory study

AIM

To evaluate the factors associated with treatment dropout among patients attending the psychiatric outpatient services.

MATERIALS AND METHODS

Seventy-two patients who dropped out from treatment were contacted and they were compared with 200 regular attendees for sociodemographic and clinical variables, medication adherence, treatment satisfaction, attitude toward medication, insight, and therapeutic alliance.

RESULTS

Compared to "regular attendees," those who dropped out from treatment were significantly older, were more likely to be married, had higher age of onset, had longer duration of illness, received less supervision for medication at home, higher proportion of them continued to remain symptomatic, had more negative attitude toward medications, had poorer insight, were poorly complaint with medication, were less satisfied with the treatment provided, and had poor quality of therapeutic alliance.

CONCLUSION

This study suggests that dropout from treatment can be avoided by addressing issues of negative attitude toward medications, improving satisfaction with the treatment contact and enhancing therapeutic alliance.

Treatment of Mental Illness Prior to Suicide: A National Investigation of 12,909 patients, 2001-2016

OBJECTIVE

Previous research suggests that up to 90% of individuals who die by suicide may have a mental disorder at the time of death but that levels of treatment may be low. This study aimed to examine undertreatment among patients with mental health conditions who died by suicide and to assess the association between patients' clinical and sociodemographic characteristics and treatment receipt.

METHODS

The study's sample included 12,909 patients in England and Wales who died by suicide within 12 months of contact with mental health services between 2001 and 2016. All patients had received a diagnosis of bipolar affective disorder, schizophrenia, depression, or an anxiety disorder. Records of patients who were not receiving treatment as recommended by national clinical guidelines at the time of death were examined for levels of nonprescription of treatment and nonadherence.

RESULTS

Twenty-four percent of the patients did not receive treatment, 11% had not been prescribed treatment, and 13% were nonadherent with treatment. These proportions differed by diagnosis. After adjustment for main primary diagnosis, analyses showed that being under age 40, unemployment, living alone, drug misuse, medication side effects, and comorbid personality disorder were independently associated with a decreased likelihood of receiving treatment.

CONCLUSIONS

One-quarter of patients with mental health conditions who die by suicide may not be receiving relevant interventions at the time of death. Levels of and reasons for nontreatment vary by diagnosis, but measures to address comorbid diagnoses and implement interventions to improve adherence in specific groups could have an impact.

Cognitive-motivational, interpersonal, and behavioral functioning in relationship to treatment and research engagement in forensic patients with ADHD

Objectives

To provide more insight into treatment and research responsivity in offenders with attention‐deficit hyperactivity disorder (ADHD).

Method

Via self‐reports and patients' scores on cognitive computer tasks, it was examined whether poorer cognitive‐motivational, interpersonal, and behavioral functioning were related to treatment no‐shows, longer treatment time duration intervals, and no‐show at the research appointment in 52 forensic outpatients with ADHD (M_age = 35.3, SD = 9.38). Treatment adherence was tracked for 10 appointments after research participation.

Results

Regression analyses showed that higher self‐reported impulsivity was associated with research no‐show, and more alcohol use with longer treatment time intervals. Yet, self‐reported delay aversion was associated with fewer treatment no‐shows, and, uncontrolled for alcohol use, impulsivity was associated with shorter treatment time intervals in a subsample of patients.

Conclusions

These preliminary results indicate that externalizing behaviors increase the risk for nonadherence in forensic ADHD patients, but that cognitive‐motivational problems also motivate patients to be more engaged.

The role of personality disorder in ‘difficult to reach’ patients with depression: Findings from the ODIN study

Individuals with personality disorders (especially paranoid personality disorder) tend to be reluctant to engage in treatment. This paper aimed to elucidate the role of personality disorder in predicting engagement with psychological treatment for depression. The Outcomes of Depression International Network (ODIN) involves six urban and three rural study sites throughout Europe at which cases of depression were identified through a two-stage community survey. One patient in seven who was offered psychological treatment for depression had a comorbid diagnosis of personality disorder (most commonly paranoid personality disorder). Forty-five percent of patients who were offered psychological treatment for depression did not complete treatment. The odds of completion were higher for patients with a comorbid diagnosis of personality disorder, especially paranoid, anxious or dependent personality disorder. The relatively low number of cases with some specific personality disorders (e.g. schizoid personality disorder) limited the study's power to reach conclusions about these specific disorders. This study focused on a community-based sample which may lead to apparently lower rates of engagement when compared to studies based on treatment-seeking populations. Episodes of depression in the context of personality disorder may represent a valuable opportunity to engage with patients who might otherwise resist engagement.

Impact of Quality Rights Gujarat program on dropout rate of patients visiting outpatient psychiatry department of tertiary care hospital

BACKGROUND

Dropout from an outpatient clinic is the loss of patient to the scheduled follow-up. Noncompliance in the form of treatment dropouts is a major problem across outpatient mental health settings and can range from 15% to 60%. Follow-up studies provide valuable insights into improving the quality of existing mental health facilities. Quality Rights Gujarat (QRG) is a step toward improving mental health facilities across various centers.

METHODS

This retrospective observational study aims to explore follow-up pattern, predictors and any change after QRG implementation. Pre intervention Group (A) attended psychiatry OPD for 6 months before implementation of QRG project and Post intervention Group (B) attended psychiatry OPD for 3 months after implementation of QRG project.

RESULTS

Total 1632 Patients consulted in group A and 926 patients consulted Psychiatry OPD in group B. The most common Psychiatric disorder were Depression (A-19.55%, B-28.62%), Schizophrenia and related disorders (A-14.15%, B-15.01%), Neuropsychiatric disorders like headache and epilepsy (A-14.52%, B-18.68%), substance use disorder (A-15.26%, B-13.71%) and Bipolar disorder (A-11.76%, B-13.17%). 59.56% patients dropped out after the first visit in pre intervention group as compared to 51.94% patients in post intervention group. Significant reduction of about 8% in loss to follow up and 16% increase in follow-ups of initial visits after implementation of Quality Rights Gujarat project.

CONCLUSIONS

Much can be done to improve attendance in most services. The initiative like QRG significantly has positive results on patient's follow-up.

Differential impact of current diagnosis and clinical stage on attendance at a youth mental health service

AIM

To examine whether clinical stage of illness and current diagnosis influence appointment behaviour in a specialized primary-level youth mental health service.

METHODS

Factors associated with attendance at 8697 appointments made by 828 young people (females = 497) aged 12-25 years over a 1-year period were analysed.

RESULTS

The number of appointments made did not correlate with the rates of attendance. However, those with more severe psychiatric morbidity made significantly more appointments and missed significantly more appointments than those with less severe presentations. Impaired social functioning was the best predictor of female attendance rates, whereas age and clinical stage of illness best predicted male attendance rates. Current diagnosis rather than functional impairment appeared to influence the level of input offered by clinicians.

CONCLUSIONS

Age, gender, severity of illness, functioning and psychological distress had differential associations with both planned treatment intensity and attendance rates. These differences are likely to have implications for service provision in this youth population.

Assessing adherence to guidelines with administrative data in psychiatric outpatients

RATIONALE, AIMS AND OBJECTIVES

To assess (feasibility) of adherence to treatment guidelines among outpatients with common mental disorders in a routine Dutch clinical outpatient setting for common mental disorders using administrative data.

METHODS

In a retrospective cohort study, we analysed routinely collected administrative data of 5346 patients, treated for mood, anxiety or somatoform disorders with pharmacotherapy, psychotherapy or a combination of both. Available administrative data allowed assessment of guideline adherence with a disorder-independent set of five quality indicators, assessing psychotherapy, pharmacotherapy, a combination of both and routine outcome measurements (ROM) during diagnostic and therapeutic phases. Associations between the socio-demographic variables age, gender, clinical diagnosis and treatment type on the one hand and non-adherence to guidelines were tested using logistic regression analysis.

RESULTS

Patients were aged 39.5 years (SD 13.0) on average. The majority of patients were treated with a combination of pharmacotherapy and psychotherapy (50.1%), followed by psychotherapy (44.2%) and pharmacotherapy (5.6%). The majority of patients were suffering from a mood disorder (50.0%), followed by anxiety (43.9%) and somatoform disorders (6.1%). A diagnosis of anxiety or somatoform disorder was associated with higher odds of suboptimal duration [odds ratio (OR): 1.55 and 1.82[ and suboptimal frequency of psychotherapeutic treatment (OR of 0.89 and 0.63), and absence of ROM in the diagnostic phase (ORs 1.31 and 1.36, respectively) compared with depressive disorders. No ROM in the diagnostic phase was also predicted for by increasing age (ORs for the age categories of 56 and older of 1.48).

CONCLUSIONS

In this proof of principal study, we were able to assess some key indicators assessing adherence to clinical guidelines by using administrative data. Also, we could identify predictors of adherence with simple parameters available in every administrative data. Administrative data could help to monitor and aid guideline adherence in routine care, although quality may vary between settings.

Exploration of the reasons for dropping out of psychotherapy: A qualitative study

Elucidating the reasons for dropping out of psychotherapy can lead to the development of interventions aimed at reducing patient drop out. The present study aimed to explore patients' reasons for dropping out of psychotherapy in Kermanshah, Iran. The present qualitative study was performed using conventional content analysis. The current sample included 15 participants consisting of 7 patients who dropped out of psychotherapy and 8 psychotherapists who have previously experienced patient dropout. A semi-structured interview was used for data collection. All interviews were audio recorded and subsequently transcribed. Content analysis using constant comparisons was performed for transcribed interviews. Four main categories emerged as reasons for dropping out of psychotherapy: dissatisfaction with the quality of psychotherapy, financial problems in psychotherapy, unprepared socio-cultural context of psychotherapy, and psychotherapy as a non-user friendly treatment. Additionally, specific subcategories within each main category were documented. The results revealed distinct reasons for psychotherapy drop out in the current Iranian-based sample. These identified reasons should be considered and addressed at the onset of treatment as well as in the development of formal interventions aimed at reducing dropout. Further research investigating the antecedents leading to patient drop out is recommended.

Determinants of dropout in a community-based mental health crisis centre

BACKGROUND

Dropping out during the course of medical follow up is defined as an early therapy withdrawal without the agreement of the therapist. In a psychiatric crisis unit in Geneva, we empirically observed that almost 50% of the patients were not showing up to their first appointments, which were scheduled for 3 to 7 days post discharge.

METHODS

The aim of this naturalistic descriptive cohort study is to identify the demographic, patient and care-related predictive factors of dropout in a community-based psychiatric crisis centre. We included 245 consecutive outpatients followed-up for 4 to 6 weeks of intensive outpatient psychiatric treatment. Logistic regression models were built to examine the association between dropout and demographic, care and patient-related variables.

RESULTS

Among the 245 outpatients, dropout occurred in 37.5% of cases, and it most frequently occurred (81.8%) in the first 2 days of follow-up. Among care-related variables, referral by hospital units or private psychiatrists led to significantly lower levels of dropout compared to patients referred by the psychiatric emergency unit (respectively: OR = .32; p = .04; 95% CI [.10, .93]; OR = .36; p = .04; 95% CI [.13, .96]; OR = .22; p = .002; 95% CI [.08, .58]). Among patient-related variables, younger age increased the risk of dropout (OR = .96; 95%; p = .002; 95% CI [.94, .99]). Anxiety and personality but not mood disorders were also related to higher rates of dropout (respectively: OR = 2.40; p = .02; 95% CI [1.14, 4.99]; and OR = 1.98; p = .02; 95% CI [1.09, 3.59]). Unipolar depression (72.2%; OR = 1.47; p = .48; 95% CI [.34, 1.21]) was the most frequent primary diagnosis in this sample.

CONCLUSIONS

This study makes clear the need for increased efforts to improve care adherence in young patients with anxious or personality disorders seen in emergency rooms because they are prone to early discontinuation of treatments. Future studies in this field are warranted to gain a better understanding into the complex reasons that surround discontinuation of care in outpatient settings.

Genetic association analysis of N-methyl-D-aspartate receptor subunit gene GRIN2B and clinical response to clozapine

OBJECTIVE

Approximately 30% of patients with schizophrenia fail to respond to antipsychotic therapy and are classified as having treatment-resistant schizophrenia. Clozapine is the most efficacious drug for treatment-resistant schizophrenia and may deliver superior therapeutic effects partly by modulating glutamate neurotransmission. Response to clozapine is highly variable and may depend on genetic factors as indicated by twin studies. We investigated eight polymorphisms in the N-methyl-D-aspartate glutamate receptor subunit gene GRIN2B with response to clozapine.

METHODS

GRIN2B variants were genotyped using standard TaqMan procedures in 175 European patients with schizophrenia deemed resistant or intolerant to treatment. Response was assessed using change in Brief Psychiatric Rating Scale scores following six months of clozapine therapy. Categorical and continuous response was assessed using chi-squared test and analysis of covariance, respectively.

RESULTS

No associations were observed between the variants and response to clozapine. A-allele carriers of rs1072388 responded marginally better to clozapine therapy than GG-homozygotes; however, the difference was not statistically significant (p = 0.067, uncorrected).

CONCLUSIONS

Our findings do not support a role for these GRIN2B variants in altering response to clozapine in our sample. Investigation of additional glutamate variants in clozapine response is warranted.

Different Perspectives of Clinicians and Patients with Severe Mental Illness on Motivation for Treatment

The present study assessed motivation for engaging in treatment as rated by clinicians (n = 57) and patients with severe mental illness (SMI, n = 294) using measures based on three different motivation theories. Questionnaires were derived from self-determination theory, the transtheoretical model and the integral model of treatment motivation. It was investigated to which extent clinicians of patients with SMI were able to estimate their patient's perspective on motivation for engaging in treatment, to which extent they agreed on the patient's motivation and which factors were associated with estimation and agreement on treatment motivation. It was found that clinicians were poorly to moderately capable of estimating their patient's type of motivation and readiness for change. Further, agreement on the level of motivation between patients and clinicians was moderate. These findings were consistent across diagnostic groups (psychotic and personality disorders). A higher quality therapeutic relationship was generally associated with higher clinician-rated motivation. The patient's ethnicity and socially desirable responding were factors that differentiated between scales of different motivation theories. It is concluded that patients with SMI and their clinicians have different perceptions on the patient's motivation for engaging in psychiatric treatment, regardless of the theoretical framework that is used to measure motivation. The findings imply that a negotiated approach is needed where both perceptions of clinicians and patients on motivation for treatment are considered to ensure effective mental health interventions. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Clinicians show poor to moderate capability in estimating how patients perceive their motivation for engaging in treatment, especially so when the patient's motives revolve around feelings of shame and guilt. Clinicians generally give higher motivation ratings for patients where they experience a higher quality therapeutic relationships with, whereas-depending on the scale that is used to measure motivation-they give lower ratings to patients who respond in socially desirable ways and to ethnic minority patients. As patients with SMI and their clinicians have different perceptions on the patient's motivation for engaging in psychiatric treatment (regardless of the theoretical framework that is used to assess motivation), this implies that a negotiated approach is needed where both perceptions of clinicians and patients on motivation for treatment are considered to ensure effective mental health interventions.

The effects of motivation feedback in patients with severe mental illness: a cluster randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of providing clinicians with regular feedback on the patient's motivation for treatment in increasing treatment engagement in patients with severe mental illness.

DESIGN

cluster randomized controlled trial (Dutch Trials Registry NTR2968).

PARTICIPANTS

adult outpatients with a primary diagnosis of a psychotic disorder or a personality disorder and their clinicians, treated in 12 community mental health teams (the clusters) of two mental health institutions in the Netherlands.

INTERVENTIONS

monthly motivation feedback (MF) generated by clinicians additional to treatment as usual (TAU) and TAU by the community mental health teams.

PRIMARY OUTCOME

treatment engagement at patient level, assessed at 12 months by clinicians.

RANDOMIZATION

teams were allocated to MF or TAU by a computerized randomization program that randomized each team to a single treatment by blocks of varying size. All participants within these teams received similar treatment. Clinicians and patients were not blind to treatment allocation at the 12-month assessment.

RESULTS

The 294 randomized patients (148 MF, 146 TAU) and 57 clinicians (29 MF, 28 TAU) of 12 teams (6 MF, 6 TAU) were analyzed according to the intention-to-treat principle. No statistically significant differences between treatment groups on treatment engagement were found (adjusted mean difference =0.1, 95% confidence interval =-2.2 to 2.3, P=0.96, d=0). Preplanned ancillary analyses showed statistically significant interaction effects between treatment group and primary diagnosis on treatment motivation and quality of life (secondary outcomes), which were beneficial for patients with a primary diagnosis of a personality disorder but not for those with a psychotic disorder. There were no reports of adverse events.

CONCLUSION

The current findings imply that monitoring and discussing the patient's motivation is insufficient to improve motivation and treatment engagement, and suggests that more elaborate interventions for severe mental illness patients are needed.

Psychiatric services and prescription fills among veterans with serious mental illness in methadone maintenance treatment

OBJECTIVE

Comorbidity and co-prescription patterns of people with serious mental illness in methadone maintenance may complicate their treatment and have not been studied. The goal of this study was to examine the care and characteristics of people with serious mental illness in methadone maintenance treatment nationally in the Veterans Health Administration (VHA).

METHODS

Using national VHA data from FY2012, bivariate and multiple logistic regression analyses were used to compare veterans in methadone maintenance treatment wo had a serious mental illness (schizophrenia, bipolar disorder, or major affective disorder) to patients in methadone maintenance treatment without serious mental illness and patients with serious mental illness who were not in methadone maintenance treatment.

RESULTS

Only a small fraction of patients with serious mental illness were receiving methadone maintenance treatment (0.65%), but a relatively large proportion in methadone maintenance treatment had a serious mental illness (33.2%). Compared to patients without serious mental illness, patients with serious mental illness in methadone maintenance treatment were more likely to have been homeless, to have had a recent psychiatric hospitalization, to be over 50% disabled, and to have had more fills for more classes of psychotropic drugs. Compared to other patients with serious mental illness, patients with serious mental illness in methadone maintenance treatment were more likely to have a drug abuse diagnosis and to reside in large urban areas.

CONCLUSIONS

One-third of patients in methadone maintenance treatment have serious mental illness and more frequent psychiatric comorbidity, and they are more likely to use psychiatric and general health services and fill more types of psychiatric prescriptions. Further study and clinical awareness of potential drug-drug interactions in this high medication and service using population are needed.

Adherence to behavioral therapy and psychiatry visits in a safety-net setting in Virginia, USA

Little is known about predictors of adherence to outpatient behavioural therapy and psychiatry visits in those who experience homelessness. Yet, consistent receipt of services in the community is critical to preventing use of acute care psychiatric services, which cause a significant cost burden to the mental health system. This retrospective study examined sociodemographic, housing instability and health-related factors associated with adherence to behavioural therapy and psychiatry appointments among 1711 clients served by an urban healthcare for the homeless centre in Virginia, USA. Clients ≥18 years old with a behavioural health condition who had an intake assessment and at least one behavioural therapy or psychiatry appointment scheduled during October 2005-September 2009 were eligible for the study. Of those with scheduled behavioural therapy visits, 27.7% were high adherers and 19.3% did not attend any appointments, whereas of those with scheduled psychiatry visits, 13.6% were high adherers and 22.1% did not attend any appointments. African Americans, when compared with whites, and those with a primary diagnosis of bipolar disorder were less likely to be high adherers to behavioural therapy. Women and being ≥35 years old were associated with a decreased likelihood of failing to attend psychiatry appointments, whereas African Americans, when compared with whites, and those with co-occurring disorders were more likely to not attend any psychiatry appointments. Understanding factors related to adherence to behavioural health services can help homeless care providers tailor strategies for improving visit adherence.

Treatment modality preferences and adherence to group treatment for panic disorder with agoraphobia

To examine the relationship between preference for group psychotherapy and adherence to group cognitive-behavioral therapy (CBT) for clients with panic disorder with agoraphobia (PDA), 109 participants experiencing PDA completed a questionnaire measuring preference for group treatment (PGTQ) before beginning CBT groups. A t test was used to compare preference scores for group treatment to investigate whether participants who completed treatment differed from those who abandoned treatment. Participants who completed group therapy expressed higher preference for group treatment than participants who dropped out of treatment (t[107] = 1.99; p < 0.05). The PGTQ-4 presented adequate psychometric properties. Reliability analyses of the items retained after factorization demonstrated an acceptable level of internal consistency (Cronbach's alpha of 0.76). Preference for individual or group therapy appears to impact treatment retention for patients with PDA. Matching patients' preferences to the type of treatment modality used appears to be pertinent, especially for the treatment of anxiety disorders. In terms of practical implications, the rationale and benefits of group therapy should be explained to participants reluctant to engage in group therapy. Individual intervention or a combination of group and individual treatment could be considered for clients who are likely to drop out of group therapy.

Mavacoxib and meloxicam for canine osteoarthritis: a randomised clinical comparator trial

NSAIDs are the cornerstone of medical management of canine osteoarthritis (OA). Meloxicam is a daily-administered NSAID widely available in a liquid formulation and manufacturer's summary of product characteristics (SPC) advise that it is given at the lowest effective dose. Mavacoxib is a long-acting NSAID given as a monthly tablet. This study compares these drugs in the management of canine OA. In all, 111 dogs with OA of the elbow, hip or stifle were randomly assigned to receive one of these NSAIDs for a 12-week period, and to administer them as per the manufacturer's SPC. Outcomes, including ground reaction forces and three validated clinical metrology instruments, were measured at baseline, 6 and 12 weeks. Improvements were seen in all outcome measures for both groups to a similar degree, and adverse events occurred at a similar rate. There were significant improvements in outcome measures from week 6 to week 12, as well as from baseline. Long-term meloxicam dose was more important than recent dose. Clinical efficacy and adverse event rates are similar for meloxicam and mavacoxib when administered as per their UK SPC. This is relevant information for veterinary surgeons when prescribing NSAID treatment for canine OA.

A systematic narrative review of the literature: adherence to pharmacological and nonpharmacological treatments among adolescents with mental disorders

AIMS AND OBJECTIVES

To review current research into the adherence to mental health treatment by adolescents.

BACKGROUND

Nonadherence to medication among adolescents has been studied much more extensively than nonadherence to other forms of treatment. Monitoring adherence to all recommended services is essential when assessing the long-term effectiveness of different treatment programmes. Healthcare professionals who treat patients with mental illness must be able to accurately determine which of their patients are adhering to all prescribed treatments.

DESIGN

This is a systematic narrative literature review of the current literature.

METHODS

Using a narrative synthesis, the data from 15 relevant articles concerning adolescents in inpatient or outpatient mental health care were extracted and synthesised.

RESULTS

The reviewed papers are discussed in terms of the methods used to study treatment adherence, the working definition of adherence used in each case and the results obtained concerning adherence in adolescents. Thirty-four to sixty-seven per cent of adolescents treated are fully adherent to their medication and exhibit reasonably good follow-through for the recommended treatments. However, rates of noncompliance with medication are quite high, and significant numbers of adolescents choose to discontinue their medication.

CONCLUSIONS

This review synthesises current published data on adherence to mental health treatment among adolescents in order to provide practitioners and researchers with a better understanding of this important area. It is recommended that future investigations should focus on adherence in inpatient care, adherence to nonpharmacological treatments and the identification of factors that influence adherence.

RELEVANCE TO CLINICAL PRACTICE

The monitoring and understanding of adherence to recommended services is important. Therefore, these findings can be used by healthcare professionals who treat patients with mental illness to help them assess which of their patients are adhering to the prescribed treatments.

Predictors and moderators of aftercare appointment-keeping following brief motivational interviewing among patients with psychiatric disorders or dual diagnosis

OBJECTIVE

Non-adherence to psychiatric and substance abuse treatment recommendations, especially with regard to aftercare outpatient appointment-keeping following hospitalizations, exacts a high cost on mental health spending and prevents patients from receiving therapeutic doses of treatment. Our primary objective was to evaluate the relationship between potential predictors and moderators of aftercare appointment-keeping among a group of adult patients immediately following hospitalization for severe psychiatric disorders or dual diagnosis.

METHODS

Candidate predictors and moderator variables included demographics, psychiatric status, psychiatric symptom severity, and inpatient group adherence, while aftercare appointment-keeping was defined as attendance at the first aftercare appointment. Participants were 121 adult inpatients with a psychiatric disorder or dual diagnosis originally enrolled in an earlier randomized controlled trial comparing standard treatment with standard treatment plus brief motivational interviewing for increasing adherence.

RESULTS

RESULTS indicated that, across treatment conditions, those who were female, did not have dual diagnosis, were older (older than 33 years), and were less educated (<high school) attended their first aftercare appointment at significantly higher rates than their counterparts. A treatment-by-gender interaction was noted, where only men were significantly more likely to keep their first aftercare appointment if they received standard treatment plus brief motivational interviewing, compared to standard treatment alone (OR = 9.58, p < .001).

CONCLUSIONS

Findings suggest that gender, dual diagnosis status, age and education may be an important predictors of aftercare treatment adherence and that gender may be a moderator of motivational interviewing among individuals with psychiatric disorders or dual diagnosis.

Dropping out of outpatient psychiatric treatment: a preliminary report of a 2-year follow-up of 1500 psychiatric outpatients in Kermanshah, Iran

BACKGROUND

Outpatient psychiatric treatment provides both psychotherapy and pharmacotherapy for a large portion of psychiatric patients. Dropping out, or early termination of treatment, may be considered a common barrier to outpatient's psychiatric treatment. There are limited studies on this issue in Iran. The current study aimed to examine rates, predictors and reasons of dropping out of an outpatient psychiatric treatment.

MATERIALS AND METHOD

In this 6-month cohort study, 1500 outpatients who visited 10 psychiatrist's offices in the Iranian city of Kermanshah were recruited and followed for 2 years (2009-2011) for recommended treatments including admission to hospital, pharmacotherapy, psychotherapy and a combination of both psychotherapy and pharmacotherapy. Characteristics of patients who dropped out of the current study were collected, and reasons for dropping out were collected via phone or in person interview.

RESULTS

Dropouts were prevalent in prescribed treatments. Pretreatment (primary) dropout rates in psychotherapy treatment were 4 times greater than dropout rates in pharmacotherapy treatment (80% and 20%, respectively). There were significance differences between dropouts and non-dropouts of pharmacotherapy with respect to patient characteristics; younger age, male gender, low level of education, unemployment, lack of insurance, new cases and divorce were more prevalent among dropouts (P<.001). With regard to diagnosis, dropping out was more prevalent among patients with substance-related disorders, schizophrenia and other psychotic disorders when compared to other diagnoses (P<.001). Commonly reported reasons for dropping out included overslept and too ill to attend treatment and fear of becoming addicted to prescribed psychotropic medication (30% and 18%, respectively). Lack of confidence in therapist ability and lack of confidence in the efficacy of the treatment were more prevalent in patients who dropped out of psychotherapy (P<.001).

CONCLUSION

Patient dropout is a common problem in outpatient psychiatric treatment, particularly in psychotherapy treatment. Further research on reasons for dropping out and strategies to reduce rates of dropouts is recommended.

Is treatment adherence consistent across time, across different treatments and across diagnoses?

OBJECTIVE

The objective was to examine consistency of adherence across depression treatments and consistency of adherence between depression treatments and treatments for chronic medical illness.

METHODS

For 25,456 health plan members beginning psychotherapy for depression between 2003 and 2008, health plan records were used to examine adherence to all episodes of psychotherapy, antidepressant medication, antihypertensive medication and lipid-lowering medication.

RESULTS

Within treatments, adherence to psychotherapy in one episode predicted approximately 20% greater likelihood of subsequent psychotherapy adherence [odds ratio (OR)=2.20, 95% confidence interval (CI) 1.83-2.64]. Similarly, adherence to antidepressant medication in one episode predicted approximately 20% greater likelihood of subsequent antidepressant adherence (OR=1.99, 95% CI 1.74-2.28). Across treatments, adherence to antidepressant medication predicted approximately 10% greater likelihood of concurrent or subsequent adherence to psychotherapy (OR=1.52, 95% CI 1.42-1.63), a 4% greater likelihood of adherence to antihypertensive medication (OR=1.24, 95% CI 1.14-1.37) and a 3% greater likelihood of adherence to lipid-lowering medication (OR=1.16, 95% CI 1.03-1.32). Adherence to psychotherapy predicted a 2% greater likelihood of concurrent or subsequent adherence to antihypertensive medication (OR=1.11, 95% CI 1.04-1.19) and was not a significant predictor of adherence to lipid-lowering medication (OR=0.99, 95% CI 0.90-1.18).

CONCLUSIONS

Adherence is moderately consistent across episodes of depression treatment. Depression treatment adherence is a statistically significant, but relatively weak, predictor of adherence to antihypertensive or lipid-lowering medication.

Motivation and treatment engagement intervention trial (MotivaTe-IT): the effects of motivation feedback to clinicians on treatment engagement in patients with severe mental illness

BACKGROUND

Treatment disengagement and non-completion poses a major problem for the successful treatment of patients with severe mental illness. Motivation for treatment has long been proposed as a major determinant of treatment engagement, but exact mechanisms remain unclear. This current study serves three purposes: 1) to determine whether a feedback intervention based on the patients' motivation for treatment is effective at improving treatment engagement (TE) of severe mentally ill patients in outpatient psychiatric treatment, 2) to gather insight into motivational processes and possible mechanisms regarding treatment motivation (TM) and TE in this patient population and 3) to determine which of three theories of motivation is most plausible for the dynamics of TM and TE in this population.

METHODS/DESIGN

The Motivation and Treatment Engagement Intervention Trial (MotivaTe-IT) is a multi-center cluster randomized trial investigating the effectiveness of feedback generated by clinicians regarding their patients' treatment motivation upon the patients' TE. The primary outcome is the patients' TE. Secondary outcomes are TM, psychosocial functioning and quality of life. Patients whose clinicians generate monthly motivation feedback (additional to treatment as usual) will be compared to patients who receive treatment as usual. An estimated 350 patients, aged 18 to 65 years, with psychotic disorders and/or severe personality disorders will be recruited from outpatient community mental health care. The randomization will be performed by a computerized randomization program, with an allocation ratio of 1:1 (team vs. team or clinician vs. clinician) and patients, but not clinicians, will be blind to treatment allocation at baseline assessment. Due to the nature of the trial, follow-up assessment can not be blinded.

DISCUSSION

The current study can provide important insights regarding motivational processes and the way in which motivation influences the treatment engagement and clinical outcomes. The identification of possible mechanisms through which changes in the outcomes occur, offers a tool for the development of more effective future interventions to improve TM and TE.

TRIAL REGISTRATION

Current Controlled Trials NTR2968.

Early dropout from psychotherapy for depression with group- and network-model therapists

Administrative data were used to examine early dropout among 16,451 health plan members calling to request psychotherapy for depression. Compared to members referred to group-model therapists, those referred to network-model therapists were more likely to drop out before the initial visit (OR 2.33, 95% CI 2.17-2.50) but less likely to drop out after the first visit (OR 0.45, 95% CI 0.43-0.48). These differences were unaffected by adjustment for neighborhood income and educational attainment, antidepressant use, or generosity of insurance coverage. Efforts to increase the effectiveness of psychotherapy may required different strategies in group- and network-model practice.

Is dropout after a first psychotherapy visit always a bad outcome?

OBJECTIVE

The authors compared outcomes reported by patients who did or did not return for treatment after an initial psychotherapy visit.

METHODS

Members of a group health plan were surveyed about initial psychotherapy visits occurring between March and September 2010. The survey assessed satisfaction with care and therapeutic alliance during the visit and later clinical improvement.

RESULTS

Of the 2,666 members who returned surveys, 906 (34%) did not return for a second visit within 45 days. The distribution of satisfaction, therapeutic alliance, and self-rated improvement scores between patients who did and did not return differed significantly (p<.001). Patients who did not return were more likely to report the most favorable and the least favorable outcomes.

CONCLUSIONS

Failure to return after an initial psychotherapy visit can represent successful and satisfying treatment. Systematic outreach and outcome assessment are necessary to identify the patients who drop out of therapy after unsuccessful and unsatisfying treatment.

Vitality predicts level of guideline-concordant care in routine treatment of mood, anxiety and somatoform disorders

OBJECTIVE

To examine the clinical and psychosocial correlates of adherence to treatment guidelines among outpatients with common mental disorders in a routine clinical setting.

METHODS

In this retrospective cohort study, we analysed 192 patients who were treated for a mood, anxiety or somatoform disorder with pharmacotherapy, psychotherapy or a combination of both treatment modalities. Guideline adherence was assessed with a disorder independent set of quality indicators during up to 3 years of follow-up. At baseline, a standardized diagnostic interview, the Brief Symptom Inventory (BSI), the Short Form 36 (SF-36) and demographic variables were assessed. Using multivariable regression analysis we identified independent predictors associated with guideline adherence.

RESULTS

Patients were aged 36.8 years (SD 11.6) on average. The majority of patients were treated with psychotherapy (47.4%), followed by pharmacotherapy (37.5%) and a combination of pharmacotherapy and psychotherapy (15.1%). Three adherence groups were defined: low (29.7%), intermediate (43.2%) and high (27.1%). Univariate predictors of low adherence were low scores on the subscales vitality and social functioning of the SF-36. In the multivariable model, low adherence was independently predicted by a score lower than 50 on the subscale vitality of the SF-36 (odds ratio per 10 units increase in vitality = 1.34, 95% confidence interval: 1.06-1.71). No significant differences were found within socio-demographic variables, co-morbidity and the scores on the BSI subscales between the adherence groups.

CONCLUSIONS

We found that patients with low scores on the vitality subscale of the SF-36 were at the highest risk to receive low guideline-concordant care. Understanding factors that affect treatment adherence may help to prevent non-adherence and increase the quality of care as well as cost-effectiveness.

A mathematical model of psychotherapy: an investigation using dynamic non-linear equations to model the therapeutic relationship

Mathematical models, such as the one developed by Gottman et al. (1998, 2000, 2002) to understand the interaction between husbands and wives, can provide novel insights into the dynamics of the therapeutic relationship. A set of nonlinear equations were used to model the changing emotional state of a therapist and client. The results suggest: (1) The person that is most responsive to the other achieves the most positive state, (2) the emotional state of the client oscillates before reaching its final state, (3) therapy is least successful when the therapist starts from a negative state, and (4) there is an inverse relationship between models that change only the influence parameter and models that change only the inertia parameter, creating a series of four basic models to work with. These theoretical models require further, empirical investigation to test the derived parameters. If validated, or revised based on observations of therapist-client relationships in development, they could provide specific direction in creating successful therapeutic relationships for training clinicians and those already in practice.

Factors associated with attrition from a randomized controlled trial of meaning-centered group psychotherapy for patients with advanced cancer

OBJECTIVE

The generalizability of palliative care intervention research is often limited by high rates of study attrition. This study examined factors associated with attrition from a randomized controlled trial comparing meaning-centered group psychotherapy (MCGP), an intervention designed to help advanced cancer patients sustain or enhance their sense of meaning to the supportive group psychotherapy (SGP), a standardized support group.

METHODS

Patients with advanced solid tumor cancers (n = 153) were randomized to eight sessions of either the MCGP or SGP. They completed assessments of psychosocial, spiritual, and physical well-being pretreatment, midtreatment, and 2 months post-treatment. Attrition was assessed in terms of the percent of participants who failed to complete these assessments, and demographic, psychiatric, medical, and study-related correlates of attrition were examined for the participants in each of these categories.

RESULTS

The rates of attrition at these time points were 28.1%, 17.7%, and 11.1%, respectively; 43.1% of the participants (66 of 153) completed the entire study. The most common reason for dropout was patients feeling too ill. Attrition rates did not vary significantly between study arms. The participants who dropped out pretreatment reported less financial concerns than post-treatment dropouts, and the participants who dropped out of the study midtreatment had poorer physical health than treatment completers. There were no other significant associations between attrition and any demographic, medical, psychiatric, or study-related variables.

CONCLUSIONS

These findings highlight the challenge of maintaining advanced cancer patients in longitudinal research and suggest the need to consider alternative approaches (e.g., telemedicine) for patients who might benefit from group interventions but are too ill to travel.

No-shows, drop-outs and completers in psychotherapeutic treatment: demographic and clinical predictors in a large sample of non-psychotic patients

BACKGROUND

A primary challenge in mental health services is a high rate of non-attendance (i.e. no-show and drop-out) for patients referred to treatment for psychiatric disorders.

AIM

The aim of the present study was to assess the influence of demographic and clinical variables on mental health treatment attendance and to investigate differences in predictors for no-shows and drop-outs.

METHODS

A naturalistic study of 2473 non-psychotic consecutive patients offered psychotherapeutic treatment at a community mental health centre in Denmark. Fifteen demographic and clinical variables were recorded at assessment. Bivariate and multiple logistic regression analyses were conducted to investigate the associations between these variables and no-show and drop-out.

RESULTS

Of the 2473 participants, 668 (27.0%) did not show up for treatment, whereas 290 (11.7%) dropped out of treatment. Regression analysis showed that the significant predictors of treatment no-show were: age below 25, no more than the compulsory 9 years of school education, no sick leave, a diagnosis of personality disorder, a Global Assessment of Functioning score (GAF) below 40 or above 70, no previous psychiatric/psychological treatment, no use of antidepressants and substance abuse. The significant predictors of treatment drop-out were: age below 45, no more than the compulsory 9 years of school education or up to 11 years of school education, no vocational/university education, unemployment and substance abuse.

CONCLUSION

No-show was predicted by both demographic and clinical factors, whereas drop-out was predicted by demographic factors and substance abuse as the only clinical factor. Results and strategies to reduce non-attendance are discussed.

Correlates of Psychological Distress and Major Depressive Disorder Among African American Men

This study examines the demographic correlates of depressive symptoms, serious psychological distress (SPD), and major depressive disorder (MDD; 12-month and lifetime prevalence) among a national sample of African American men. Analysis of the National Survey of American Life (NSAL) data set provides first-time substantiation of important demographic differences in depressive symptoms (measured by the Center for Epidemiological Studies Depression scale [CES-D]), SPD (measured by the K6), and 12-month and lifetime MDD among African American men. Findings illuminate the heterogeneity within the African American male population. Findings also demonstrate the need for additional research focusing on within-group differences and a comprehensive research and mental health promotion agenda that recognizes the importance of improving access to education and employment and promoting healthy coping behaviors, while acknowledging the larger social context in which African American men live.

Association between prior authorization for medications and health service use by Medicaid patients with bipolar disorder

OBJECTIVE

This study examined the association between a Medicaid prior-authorization policy for second-generation antipsychotic and anticonvulsant agents and medication discontinuation and health service use by patients with bipolar disorder.

METHODS

A pre-post design with a historical comparison group was used to analyze Maine Medicaid and Medicare claims data. A total of 946 newly treated patients were identified during the eight-month policy (July 2003-February 2004), and a comparison group of 1,014 was identified from the prepolicy period (July 2002-February 2003). Patients were stratified by number of visits to community mental health centers (CMHCs) before medication initiation (proxy for illness severity): CMHC attenders, at least two visits; nonattenders, fewer than two. Changes in rates of medication discontinuation and outpatient, emergency room, and hospital visits were estimated.

RESULTS

Compared with nonattenders, at baseline CMHC attenders had substantially higher rates of comorbid mental disorders and use of medications and health services. The policy was associated with increased medication discontinuation among attenders and nonattenders, reductions in mental health visits after discontinuation among attenders (-.64 per patient per month; p<.05), and increases in emergency room visits after discontinuation among nonattenders (.16 per patient per month; p<.05). During the eight-month policy period, the policy had no detectable impact on hospitalization risk.

CONCLUSIONS

The prior-authorization policy was associated with increased medication discontinuation and subsequent changes in health service use. Although small, these unintended effects raise concerns about quality of care for a group of vulnerable patients. Long-term consequences of prior-authorization policies on patient outcomes warrant further investigation.

Meta-analysis of rates of drop-out from psychosocial treatment among persons with schizophrenia spectrum disorder

Non-compliance with pharmacotherapy among persons suffering from schizophrenia disorders stands at an average rate of 42% and is the subject of numerous studies. However, no studies to date have addressed the specific question of non-compliance with psychosocial treatment. The present study therefore aimed to determine the rate of drop-out from psychosocial treatment and to assess the influence of factors on this rate.

METHOD

A meta-analysis was conducted based on 74 studies of randomized clinical trials on psychosocial treatment among persons suffering from schizophrenia spectrum disorder.

RESULTS

A drop-out rate of 13% was obtained. Age, gender, duration of illness, duration of treatment, treatment setting and study quality affected drop-out rates.

CONCLUSION

The 13% rate of drop-out from psychosocial treatment is markedly lower than the drop-out rate from pharmacotherapy studies. This finding supports the feasibility of evidence-based psychosocial treatment - which has, moreover, clearly been shown to be clinically effective - as part of a complete care program for schizophrenia.

Depression care in the United States: too little for too few

OBJECTIVE

To determine the prevalence and adequacy of depression care among different ethnic and racial groups in the United States.

DESIGN

Collaborative Psychiatric Epidemiology Surveys (CPES) data were analyzed to calculate nationally representative estimates of depression care.

SETTING

The 48 coterminous United States.

PARTICIPANTS

Household residents 18 years and older (N = 15 762) participated in the study.

MAIN OUTCOME MEASURES

Past-year depression pharmacotherapy and psychotherapy using American Psychiatric Association guideline-concordant therapies. Depression severity was assessed with the Quick Inventory of Depressive Symptomatology Self-Report. Primary predictors were major ethnic/racial groups (Mexican American, Puerto Rican, Caribbean black, African American, and non-Latino white) and World Mental Health Composite International Diagnostic Interview criteria for 12-month major depressive episode.

RESULTS

Mexican American and African American individuals meeting 12-month major depression criteria consistently and significantly had lower odds for any depression therapy and guideline-concordant therapies despite depression severity ratings not significantly differing between ethnic/racial groups. All groups reported higher use of any past-year psychotherapy and guideline-concordant psychotherapy compared with pharmacotherapy; however, Caribbean black and African American individuals reported the highest proportions of this use.

CONCLUSIONS

Few Americans with recent major depression have used depression therapies and guideline-concordant therapies; however, the lowest rates of use were found among Mexican American and African American individuals. Ethnic/racial differences were found despite comparable depression care need. More Americans with recent major depression used psychotherapy over pharmacotherapy, and these differences were most pronounced among Mexican American and African American individuals. This report underscores the importance of disaggregating ethnic/racial groups and depression therapies in understanding and directing efforts to improve depression care in the United States.

Health and economic burden of metabolic comorbidity among individuals with bipolar disorder

OBJECTIVES

To compare the prevalence and health care costs of metabolic conditions in patients with bipolar disorder to age- and sex-matched control patients using a large insurance claims database.

METHODS

A retrospective analysis of medical service and prescription claims from the Thomson Reuters (Healthcare) MarketScan Commercial Database (which includes claims information on >12 million employees with employer-based insurance and their dependents in the United States) was conducted. Claims data for 28,531 patients with bipolar disorder were compared for 1 year with data for 85,593 age- and sex-matched control patients with no mental health disorders and no psychotropic medication use.

RESULTS

Patients with bipolar disorder had a significantly higher prevalence of metabolic comorbidities than the general population (37% vs 30%, P < 0.0001), and annual medical service treatment costs for metabolic conditions were twice that of the control cohort (531 dollars vs 233 dollars, P < 0.0001). The bipolar cohort had significantly higher overall medical service and prescription drug costs than those of the control cohort (12,764 dollars vs 3,140 dollars, P < 0.0001). Prescription medication costs for metabolic conditions were higher as well, with bipolar cohort per-patient costs of 571 dollars versus 301 dollars for the control cohort (P < 0.0001).

CONCLUSIONS

Patients with bipolar disorder have significantly more metabolic comorbidities and higher medical costs than age- and sex-matched controls. Studies that link claims data with medical records or primary data collection pertaining to metabolic conditions may overcome limitations in the diagnostic information and outcome predictors. To reduce the medical and economic burden of bipolar disorder, strategies should be identified to prevent the development of metabolic comorbidities and improve medication adherence.

Factors predicting drop-out in community mental health centres

This study aimed to identify treatment, therapist and patient factors associated with dropping out of treatment in four outpatient mental health services. The experimental group comprised all 789 individuals who attended for the first time the mental health services during one year and dropped out of treatment in the same year or during the two following ones. The control group consisted of the same number of individuals, chosen at random from patients who, in the same year, attended for the first time the services and did not subsequently drop out of treatment. The overall drop-out rate was 33.2%. According to logistic regression analysis, the predictive factors of dropping out were: being treated in a particular centre, the involvement of more than one therapist in treatment, having no previous history of psychiatric disorders, being young and being male.

Evaluating mental health services in a Greek community. The factor of non-compliance to therapy

This study aims to evaluate rendered mental health services for children and adolescents through the investigation of those factors which are related to non-compliance with therapy and which affect treatment outcome. Data were collected from the files of all new cases who applied to a Community Mental Health Centre in Athens during 2000-2002 (N = 363). For each case, the following factors were examined: age, sex, family situation, parents' educational level, referral source, child's psychiatric and psychosocial diagnoses, type of proposed therapy, phase at which termination of therapy occurred and outcome. Around 45.7% of the sample did not complete therapy. The probability of treatment compliance increased when the patient was male, with a diagnosis of a specific developmental disorder, treated in a well-structured therapy programme, was from a healthy family environment and his mother was better educated. On the contrary, an adverse family situation (one-parent family, inadequate parental supervision) and the female sex had a negative association with treatment compliance. Most of the cases discontinued their treatment upon completion of the diagnostic procedure. Referral source did not influence treatment compliance. Evaluation of our service has shown that more attention should be paid to less-educated families and those in adverse situations, particularly when the patient is female.

Adesão ao tratamento psicofarmacológico

Nesta revisão de literatura procuramos identificar os principais conteúdos relacionados à adesão do doente mental ao tratamento psicofarmacológico: definições, implicações, resultados. Realizamos a revisão bibliográfica nas bases Medline e Pubmed com as palavras chave adesão, medicação antipsicótica e doença mental. Foram selecionados 52 trabalhos. A maioria deles (73 %) buscou identificar fatores que podem influenciar adesão aos tratamentos. Os 27% restantes buscaram avaliar a influência de intervenções profissionais na adesão. Os principais fatores relatados relacionaram-se ao paciente, tipo de medicamento, fatores sociais. Com respeito às intervenções, aquelas que combinaram estratégias educacionais e comportamentais foram mais eficientes.