Effect of patient education on medication compliance

Antipsychotic Adherence Intervention for Veterans over 40 with Schizophrenia: Results of a Pilot Study

This pilot study tested the feasibility, acceptability, and effect-sizes of a multimodal, individual intervention designed to optimize antipsychotic medication use in patients >/=40 years of age with schizophrenia or schizoaffective disorder. METHODS: We randomized 40 patients into two groups: usual care (UC) or a nine-session, manualized, antipsychotic adherence intervention (AAI). The AAI attempted to improve adherence by combining three psychosocial techniques: a) education, b) skills training, and c) alliance building. Sessions employed a semi-structured format to facilitate open communication. The primary outcome was antipsychotic adherence at study end. We obtained qualitative data regarding patient preferences for the duration and modality for receiving the adherence intervention. RESULTS: Compared to the UC group, a greater proportion of the AAI group was adherent post-intervention (65% vs. 55.6%; OR=1.49), a difference that was statistically not significant. The entire AAI group reported that they intended to take medications, and 75% were satisfied with the intervention. CONCLUSIONS: The AAI was feasible and acceptable. Preliminary data on its effectiveness warrant a larger study. Qualitative data shows that patients prefer brief adherence interventions and accept telephone strategies.

Educating Psychiatric Patients about their Treatment: Do Fact Sheets Work?

Psychiatric patients are sometimes given fact sheets about their treatment but the benefits of these are uncertain. We tested three strategies in three cohorts of psychiatric inpatients—fact sheets alone, fact sheets and subsequent discussion, and control. Knowledge of medication was assessed by questionnaire.

For various reasons, only 33 of the 77 patients were included in the study or analysis. Of the patients who had been given fact sheets, 87% independently read them and reported finding them helpful whilst all asked for more information. Receiving a fact sheet alone had no significant effect, whereas having discussed it with a health care professional was associated with a significant increase in knowledge about medication. Patients receiving fact sheets selectively learned more about side-effects than about drug action or precautions.

This strategy for patient education could be used by ward nurses and deserves further evaluation.

New psychological treatments in schizophrenia

The first line of treatment for patients with psychotic disorders such as schizophrenia is neuroleptic medication. Neuroleptics have provided substantial benefits to patients with this type of severe mental illness since their discovery as a treatment for psychosis in the 1950s. Despite this, there are still a large number of patients who do not respond fully to neuroleptic medication or who are not able to tolerate it. For example, although as many as 70% of patients are substantially improved following drug treatment, a considerable proportion continue to experience persistent, distressing and recurrent symptoms. In a survey of patients in a London psychiatric hospital, Curson et al (1988) found that just under half of the patients continued to experience hallucinations and delusions despite the prescription of medication. In addition, many patients experience intolerable side-effects or do not wish to comply with neuroleptic medication, yet look for some effective alternative. Depression, anxiety and a high rate of suicide are additional problems faced by patients with schizophrenia.

Delayed follow-up in patients with diabetic retinopathy in South India: Social factors and impact on disease progression

Purpose:

To identify social factors associated with delayed follow-up in South Indian patients with diabetic retinopathy (DR) and to study DR progression during the delayed follow-up period.

Materials and Methods:

In this cross-sectional study, 500 consecutive patients with DR returning after greater than twice the advised follow-up period were identified from a tertiary referral center in South India. A previously validated 19-item questionnaire was administered to study patients to assess causes for the follow-up delay. Patient demographics, DR status, and treatment plan were recorded at the study visit and the visit immediately before the delay. The eye with the most severe disease was included in the analysis.

Results:

Complete data were available for 491 (98.2%) patients. Among these, 248 (50.5%) cited “my eyes were okay at the time,” 201 (41.0%) cited “no attender to accompany me,” and 190 (38.6%) cited “financial cost” as causes of the follow-up delay. Those with vision-threatening DR (VTDR, n = 233) predominantly reported “financial cost” (47% vs. 32%, P = 0.001), whereas those with non-VTDR more frequently reported “my eyes were okay at the time” (58% vs. 42%, P = 0.001). Evidence of disease progression from non-VTDR to VTDR was seen in 67 (26%) patients. Almost 1/3^rd (29%) of patients who were previously advised regular examination required additional intervention.

Conclusion:

Many patient-level factors affect poor compliance with follow-up in DR, and these factors vary by disease severity. Targeting these barriers to care through patient education and clinic procedures may promote timely follow-up and better outcomes in these patients.

Relationships Between World Health OrganizationInternational Classification of Functioning, Disability and HealthConstructs and Participation in Adults With Severe Mental Illness

Purpose:To examine the World Health OrganizationInternational Classification of Functioning, Disability and Health(ICF) constructs as correlates of community participation of people with severe mental illnesses (SMI).

Methods:Quantitative descriptive research design using multiple regression and correlational techniques was used to analyze 193 persons with SMI.

Results:This study examined the unique relationships between each of the ICF constructs and participation in a series of simultaneous regression analyses. Age, schizophrenia/schizoaffective diagnosis, insight, self-care activity, social competency, and social support from friends were significant predictors of participation when compared to variables in the same ICF constructs. In addition, these significant ICF predictors of participation were entered in a hierarchical regression, and only insight, social competency, and social support from friends were found to be significant predictors of participation after controlling for the effect of other ICF variables.

Conclusion:In this ICF model, insight, social competency, and social support from friends were found to be associated with participation and mediated the individual contributions of types of psychiatric disabilities and self-care activity to participation. Rehabilitation practitioners should focus on interventions that increase these factors for people with SMI. Rehabilitation researchers should continue to use the ICF as a model from which to predict participation in specific life activities (e.g., employment) for people with SMI. Continued application and validation of the ICF model could positively impact recovery-oriented outcomes for individuals with SMI.

Psychosis patients' knowledge, adherence and attitudes towards the naming of antipsychotic medication in Hong Kong

AIM

Non-adherence to medication is a common and significant challenge to successful treatment of psychosis. Knowledge of prescribed antipsychotic medication may influence psychosis patients' willingness to adhere to prescriptions. This study aimed to assess knowledge of psychosis patients on their prescribed antipsychotic medication with regard to drug name, type, dosage, purpose, side effects and reasons for taking medication, so as to investigate the associations between knowledge and adherence. The study also aimed to evaluate patient attitudes towards the current Chinese name of 'anti-psyche drug' for antipsychotic medication in Hong Kong, and survey patients' opinions on alternative names for antipsychotic medication.

METHODS

A questionnaire was administered to 70 consecutive patients from the psychiatric ward and outpatient clinic at Queen Mary Hospital in Hong Kong.

RESULTS

Current knowledge of Hong Kong psychosis patients falls short in areas of drug name (51.4% unaware), drug type (40% unaware) and prescribed dosage (28.6% unaware). The rate of self-reported non-adherence in the study sample was 38.6%. Adherence to medication was found to be positively associated with knowledge of purpose for taking medication. The current Chinese name 'anti-psyche drug' had a rating of 47/100 among psychosis patients.

CONCLUSION

Measures should be taken to improve patient knowledge in areas of drug name, type and prescribed dosage. Reminding patients about the purpose of medication may also benefit adherence and overall treatment. Finally, because of the possible stigma of the current name of antipsychotic medication, an alternative term may be more favourable in promoting its acceptance in Hong Kong.

Patient understanding of the importance of statin use in the perioperative period

OBJECTIVE

Perioperative hydroxy-3-methyl glutaryl coenzyme A reductase inhibitors (statins) have been shown to decrease morbidity and mortality after noncardiac surgery. The objective of this study was to assess patient understanding of the potential benefits of perioperative statins in a select population already on chronic therapy. A secondary aim was to determine the frequency with which patients recalled having a discussion with their provider regarding perioperative statins.

DESIGN

Survey.

SETTING

Teaching hospital.

PARTICIPANTS

Patients taking daily statins presenting to a preoperative medical evaluation clinic were offered a 12-question survey that assessed their understanding of the potential benefit of taking the medication in the perioperative period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred thirty-two patients completed the questionnaire. The mean age was 68.3 years (standard deviation, 9.0); 42% were female. The most frequent surgical referral to the clinic was orthopedics, at 36%. The most common statin prescribed was atorvastatin, in 35% of patients. Twenty-seven percent of patients (n = 36) recognized that perioperative statins are beneficial; 44% of these patients (n = 14) cited decreased cholesterol during the procedure as the reason, representing 12% of the total sampled population. Twenty-two percent (n = 8) of those recognizing the benefit of perioperative statins identified a decrease in the risk of heart attack or death as the reason. This represented only 6% of the total sample. One percent of surgeons mentioned statins in relation to the planned surgery; 2% of primary or prescribing physicians mentioned the medication in relation to surgery.

CONCLUSIONS

This study suggested low patient understanding of the potential importance and reasons for perioperative statins. In addition, this study also suggested that the information regarding the importance of perioperative statins is not being relayed to the patient at the level of the surgeon or primary care physician. All physicians involved in perioperative care can offer improved patient education to promote compliance with statin therapy in hopes of a favorable impact on perioperative outcomes.

Developments in Cognitive-Behaviour Therapy for Persistent Psychotic Symptoms

This paper is a review of studies on psychological treatments for positive psychotic symptoms, and a detailed description of two of these studies, the Manchester Symptom Project, which aimed to decrease positive symptoms by training patients in effective coping strategies, and the Liverpool Auditory Hallucination project, which aimed to provide a cognitive-behavioural treatment for individuals with persistent and distressing voices. The results from these studies indicate that enduring positive symptoms which have not responded to neuroleptic medication can be effectively treated by psychological methods.

Health literacy and the clozapine patient

AIMS

To estimate the prevalence of limited health literacy in patients receiving clozapine for schizophrenia. To develop and produce a pharmacist-designed clozapine patient information leaflet (PIL) which has a higher readability score than the company-produced PIL.

STUDY DESIGN

This was a cross sectional prevalence study.

METHODS

Ethical approval for the study was granted by the local ethics committee. Patients, over 18 years, attending the Clozapine Clinic of a Cork urban teaching hospital, were asked to participate in the study. Demographics such as gender, age, employment and smoking status, were gathered from all participants. The total daily clozapine dose, duration of clozapine treatment, and information regarding the clozapine DVD was also noted. The Rapid Estimate of Adult Literacy in Medicine (REALM) health literacy (HL) screening tool was then administered to each patient. A user-friendly PIL on clozapine was designed by the pharmacist, which was assessed for readability and compared to the company-produced PIL using the FRES and FKGL. Data were analysed using SPSS Version 15.

RESULTS

Forty patients (65% male, 95% unemployed and 70% smokers) of average age 38.0 years (+/- 11.2) completed the REALM. The average score was 60.6 (+/- 8.7). Twenty-nine patients (72.5%) were found to have "adequate" health literacy. The remaining eleven patients were found to have either "marginal" or "low" health literacy. The pharmacist-designed PIL would have been readable by 95% of the study population, in contrast to 72.5% with the company-designed PIL.

CONCLUSIONS

More than a quarter of the population were found to have marginal or low health literacy. Patient information should be matched to the health literacy level of the target population.

Increasing compliance to treatment and rehabilitation programs in patients in hospitals, outpatient and policlinic departments, and factors having an effect on compliance

The article discusses the problem of compliance, i.e. patients’ adherence to treatment and rehabilitation measures. The authors present data on possible methods for assessment of the patient’s compliance to the treatment, factors having an effect on the formation of compliance, and special techniques to be used by doctors to improve patients’ compliance to treatment.

Interventions to improve adherence to antipsychotic medication in patients with schizophrenia--a review of the past decade

OBJECTIVE

Nonadherence to antipsychotic medication is highly prevalent in patients with schizophrenia and has a deleterious impact on the course of the illness. This review seeks to determine the interventions that were examined in the past decade to improve adherence rates.

METHOD

The literature between 2000 and 2009 was searched for randomized controlled trials which compared a psychosocial intervention with another intervention or with treatment as usual in patients with schizophrenia.

RESULTS

Fifteen studies were identified, with a large heterogeneity in design, adherence measures and outcome variables. Interventions that offered more sessions during a longer period of time, and especially those with a continuous focus on adherence, seem most likely to be successful, as well as pragmatic interventions that focus on attention and memory problems. The positive effects of adapted forms of Motivational Interviewing found in earlier studies, such as compliance therapy, have not been confirmed.

CONCLUSION

Nonadherence remains a challenging problem in schizophrenia. The heterogeneity of factors related to nonadherence calls for individually tailored approaches to promote adherence. More evidence is required to determine the effects of specific interventions.

Psychoeducation for patients with bipolar disorder receiving lithium: short and long term impact on locus of control and knowledge about lithium

BACKGROUND

Psychoeducation is now considered as part of the integrated treatment for bipolar disorder. But the psychological changes involved in it have been poorly studied.

METHOD

We compared the locus of control (LOC, a key variable for health-related behaviours as well as for education practices), the knowledge about lithium [Lithium Knowledge Questionnaire (LKQ)] and attitude about lithium [Attitude towards Lithium Questionnaire (ALQ)] before and after a brief hospital based psychoeducational programme for euthymic patients with bipolar disorder (ICD-10 criteria) receiving lithium prophylaxis. The occurrence of hospitalisations was recorded during the two years before and after the patients underwent psychoeducation. All patients were reassessed after 24 months.

RESULTS

50 consecutive participants at a psychoeducational programme were evaluated. The LKQ but not the ALQ scores increased significantly after the programme. The external "powerful others" component of the LOC significantly increased after psychoeducation. The observed changes were maintained after 24 months. The patients' level of satisfaction was excellent and sustained. There was only a trend for a decrease in the rate of hospitalisations.

LIMITATIONS

The knowledge about lithium was assessed with an experimental instrument. Patients followed in a university department may not be representative of bipolar patients at large.

CONCLUSIONS

Psychoeducation enduringly increases the knowledge about lithium and induces long term changes in the locus of control that may reflect a shift in illness representations. The LOC may be an important target of psychoeducation for euthymic patients with bipolar disorder.

Progress and compliance in alcohol abuse treatment

Improving patient compliance with physicians' treatment or prescription recommendations is an important goal in medical practice. We examine the relationship between treatment progress and patient compliance. We hypothesize that patients balance expected benefits and costs during a treatment episode when deciding on compliance; a patient is more likely to comply if doing so results in an expected gain in health benefit. We use a unique data set of outpatient alcohol abuse treatment to identify a relationship between treatment progress and compliance. Treatment progress is measured by the clinician's comments after each attended visit. Compliance is measured by a client attending a scheduled appointment, and continuing with treatment. We find that a patient who is making progress is less likely to drop out of treatment. We find no evidence that treatment progress raises the likelihood of a patient attending the next scheduled visit. Our results are robust to unobserved patient heterogeneity.

Improving adherence in mood disorders: the struggle against relapse, recurrence and suicide risk

Medication nonadherence is a major obstacle to translating treatment efficacy from research settings into effectiveness in clinical practice for patients with affective disorders. Adherence to beneficial drug therapy is associated with lower mortality compared with poor adherence. Reduced adherence is associated with increased suicide risk, especially when lithium is discontinued. The aim of this paper is to review the prevalence, predictors and methods for improving medication adherence in unipolar and bipolar affective disorders. Studies were identified through Medline and PsycInfo searches of English language publications between 1976 and 2009. This was supplemented by a hand search and the inclusion of selected descriptive articles on good clinical practice. Estimates of medication nonadherence for unipolar and bipolar disorders range from 10 to 60% (median: 40%). This prevalence has not changed significantly with the introduction of new medications. There is evidence that attitudes and beliefs are at least as important as side effects in predicting adherence. The limited number of empirical studies on reducing nonadherence indicate that, if recognized, the problem may be overcome. Clinical data highlight the importance of extended courses of medication in improving the long-term prognosis of patients with affective disorders.

A systematic review of the international published literature relating to quality of institutional care for people with longer term mental health problems

BACKGROUND

A proportion of people with mental health problems require longer term care in a psychiatric or social care institution. However, there are no internationally agreed quality standards for institutional care and no method to assess common care standards across countries. We aimed to identify the key components of institutional care for people with longer term mental health problems and the effectiveness of these components.

METHODS

We undertook a systematic review of the literature using comprehensive search terms in 11 electronic databases and identified 12,182 titles. We viewed 550 abstracts, reviewed 223 papers and included 110 of these. A "critical interpretative synthesis" of the evidence was used to identify domains of institutional care that are key to service users' recovery.

RESULTS

We identified eight domains of institutional care that were key to service users' recovery: living conditions; interventions for schizophrenia; physical health; restraint and seclusion; staff training and support; therapeutic relationship; autonomy and service user involvement; and clinical governance. Evidence was strongest for specific interventions for the treatment of schizophrenia (family psychoeducation, cognitive behavioural therapy (CBT) and vocational rehabilitation).

CONCLUSION

Institutions should, ideally, be community based, operate a flexible regime, maintain a low density of residents and maximise residents' privacy. For service users with a diagnosis of schizophrenia, specific interventions (CBT, family interventions involving psychoeducation, and supported employment) should be provided through integrated programmes. Restraint and seclusion should be avoided wherever possible and staff should have adequate training in de-escalation techniques. Regular staff supervision should be provided and this should support service user involvement in decision making and positive therapeutic relationships between staff and service users. There should be clear lines of clinical governance that ensure adherence to evidence-based guidelines and attention should be paid to service users' physical health through regular screening.

Antipsychotic Adherence Intervention for Veterans over Forty with Schizophrenia: Results of a Pilot Study

This pilot study tested the feasibility, acceptability, and effect sizes of a multimodal, individual intervention designed to optimize antipsychotic medication use in patients ≥40 years of age with schizophrenia or schizoaffective disorder. Methods: We randomized forty patients into two groups: usual care (UC) versus a nine-session, manualized antipsychotic adherence intervention (AAI). The AAI attempted to improve adherence by combining three psychosocial techniques: 1) education; 2) skills training; and, 3) alliance building. Sessions employed a semistructured format to facilitate open communication. The primary outcome was antipsychotic adherence at study end. We obtained qualitative data regarding patient preferences for the duration and modality for receiving the adherence intervention. Results: Compared to the UC group, a greater proportion of the AAI group was adherent post intervention based on medication possession ratio, a commonly used measure of medication adherence (85% vs. 66.6%; OR=2.64), a difference that was statistically not significant. The entire AAI group reported that they intended to take medications, and 75% were satisfied with the intervention. Conclusions: The AAI was feasible and acceptable. Preliminary data on its effectiveness warrant a larger study. Qualitative data show that patients prefer brief adherence interventions and accept telephone strategies.

Psycho-educational groups for people with a dual diagnosis of psychosis and mild intellectual disability: a preliminary study

There have been considerable developments in psychosocial interventions for people with psychosis, but few studies on their application to individuals with a dual diagnosis of intellectual disability and psychosis. This includes the use of psycho-educational groups to develop a greater understanding of the impact of psychosis. Eight individuals with a dual diagnosis of mild to borderline intellectual disabilities and psychosis took part in a psycho-education group supported by a carer. Measures of knowledge and self-esteem were completed pre- and post-group. All participants completed the programme and measures of psychosis knowledge showed increases post-group. The participants were able to understand the concept of psychosis, the need for medication, the role of stress and early signs of relapse. This approach may help participants to have a better understanding of their condition and prepare them to cope better in the future.

Religious beliefs in schizophrenia: their relevance for adherence to treatment

The study examined how religious beliefs and practices impact upon medication and illness representations in chronic schizophrenia. One hundred three stabilized patients were included in Geneva's outpatient public psychiatric facility in Switzerland. Interviews were conducted to investigate spiritual and religious beliefs and religious practices and religious coping. Medication adherence was assessed through questions to patients and to their psychiatrists and by a systematic blood drug monitoring. Thirty-two percent of patients were partially or totally nonadherent to oral medication. Fifty-eight percent of patients were Christians, 2% Jewish, 3% Muslim, 4% Buddhist, 14% belonged to various minority or syncretic religious movements, and 19% had no religious affiliation. Two thirds of the total sample considered spirituality as very important or even essential in everyday life. Fifty-seven percent of patients had a representation of their illness directly influenced by their spiritual beliefs (positively in 31% and negatively in 26%). Religious representations of illness were prominent in nonadherent patients. Thirty-one percent of nonadherent patients and 27% of partially adherent patients underlined an incompatibility or contradiction between their religion and taking medication, versus 8% of adherent patients. Religion and spirituality contribute to shaping representations of disease and attitudes toward medical treatment in patients with schizophrenia. This dimension should be on the agenda of psychiatrists working with patients with schizophrenia.

Characteristics of voluntary participants versus nonparticipants in a psychoeducation program for euthymic patients with bipolar disorder

We aimed to assess the participation rate and predictive factors of participation in psychoeducation programs for euthymic outpatients with bipolar disorder. Ninety-five consecutive euthymic outpatients with bipolar disorder treated with lithium were recruited in a university department of psychiatry. The participants and nonparticipants in a program of psychoeducation were compared for sociodemographic, clinical, and psychological characteristics. According to univariate statistics, a younger age, a higher education level, a shorter duration of illness, a better initial knowledge about lithium, and a less external locus of control were predictive of participation in the program. A binary logistic regression model showed that an external locus of control was an independent predictor of participation. Among bipolar patients, the older, the less educated, those who have less knowledge about their treatment, and those with a more external locus of control were less likely to participate in hospital-based psychoeducation programs.

Predictors of premature antidepressant discontinuation in functional gastrointestinal disorders

OBJECTIVES

To identify factors responsible for premature antidepressant discontinuation that would assist in designing management strategies for patients with functional gastrointestinal disorders. Antidepressants are being used increasingly to manage patients with functional gastrointestinal disorders; poor patient adherence to treatment regimens, particularly in the period shortly after antidepressant initiation, is common and interferes with success.

METHODS

Clinical records were reviewed from 172 outpatients who attended a university-based practice and who had been prescribed antidepressants to manage their functional gastrointestinal symptoms. Survival analysis methods were used to determine independent predictors of premature antidepressant discontinuation (within 6 months of initiation). Logistic regression analyses were used to see if the same predictors were responsible for side effects or poor treatment response.

RESULTS

Premature antidepressant discontinuation occurred in 41 (23.8%) subjects. Somatization features (state or trait) and history of depression or an anxiety disorder were the most significant predictors of premature discontinuation (p < or = .01 for each). Advancing age and female sex also were independent predictors (p < .05 for each). Somatization features and psychiatric illness were each linked to poor treatment response, whereas somatization features most consistently were associated with antidepressant side effects.

CONCLUSIONS

Failure to maintain treatment occurs in nearly a quarter of outpatients given antidepressants for functional gastrointestinal disorders. Somatization features and history of depression or anxiety most significantly interfered with treatment by predicting side effects, poor treatment response, and premature antidepressant discontinuation. Management algorithms should include specific strategies targeted at patients with these risk factors for poor treatment adherence.

Defining and assessing adherence to oral antipsychotics: a review of the literature

The definition and assessment of adherence vary considerably across studies. Increasing consensus regarding these issues is necessary to improve our understanding of adherence and the development of more effective treatments. We review the adherence literature over the past 3 decades to explore the definitions and assessment of adherence to oral antipsychotics in schizophrenia patients. A total of 161 articles were identified through MEDLINE and PsycINFO searches. The most common method used to assess adherence was the report of the patient. Subjective and indirect methods including self-report, provider report, significant other report, and chart review were the only methods used to assess adherence in over 77% (124/161) of studies reviewed. Direct or objective measures including pill count, blood or urine analysis, electronic monitoring, and electronic refill records were used in less than 23% (37/161) of studies. Even in studies utilizing the same methodology to assess adherence, definitions of an adherent subject varied broadly from agreeing to take any medication to taking at least 90% of medication as prescribed. We make suggestions for consensus development, including the use of recommended terminology for different subject samples, the increased use of objective or direct measures, and the inclusion in all studies of an estimate of the percentage of medication taken as prescribed in an effort to increase comparability among studies. The suggestions are designed to advance the field with respect to both understanding predictors of adherence and developing interventions to improve adherence to oral antipsychotic medications.

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.

Mood disorders in the elderly

Mood disorders in the elderly are a growing source of morbidity and mortality. Unfortunately, mood disorders in later life frequently are not diagnosed and treated. Appropriate, prompt diagnosis and treatment of late-life mood disorders can significantly improve the quality of life of patients and families and may prove life saving. Current treatments can help most older adults with mood disorders. Future treatments are promising, particularly for those with treatment-resistant depression.

Educational interventions for mental health consumers receiving psychotropic medication: a review of the evidence

The objective of this systematic review is to investigate the efficacy of educational interventions, relating to psychotropic medications, for consumers with a mental health disorder. This review included only randomized controlled trials that compared the effects of various educational interventions on knowledge retention, compliance to medication and treatment, incidence of relapse, and insight into illness in patients aged 18 years and over with a mental disorder. Twenty-one trials met the quality criteria and were included in the final analysis. Patients who were provided with education demonstrated a significant increase in the level of knowledge and compliance compared with those who were not. However, there was no difference in the incidence of relapse and insight in those who were provided education. A structured education session using both written and verbal methods followed by discussion of the contents is demonstrated to be effective. The evidence suggests that consumers who were provided multiple education sessions had greater knowledge gains in the short term (up to 1 month); however, the effectiveness of multiple sessions in the long term (2 years) is inconclusive. The review provides evidence that multiple education sessions are better than single education sessions in improving knowledge relating to medications and insight into illness. Evidence from the trials demonstrates that structured educational interventions delivered at frequent intervals are useful as part of the treatment programme for people with a mental illness. More well designed and reported randomized studies investigating the efficacy of education are urgently needed.

Prediction of medication noncompliance in outpatients with schizophrenia: 2-year follow-up study

Neuroleptic noncompliance is a major reason for relapse in outpatients with schizophrenia. In a 2-year follow-up study, we used the Japanese version of the Rating of Medication Influences Scale (ROMI-J) to investigate the reasons for compliance and noncompliance in outpatients with schizophrenia. Ninety outpatients who were confirmed by interview to have had good compliance for more than 3 months completed the initial interview, which included the Clinical Global Impressions Scale (CGI), the Brief Psychiatric Rating Scale (BPRS), the Global Assessment of Functioning Scale (GAF), the UKU Side Effect Rating Scale, and the ROMI-J. All the outpatients were followed up for 2 years. At the initial interview, the most frequent reason for compliance was "relapse prevention," while the most frequent reason for noncompliance was "distressed by side effects." Fifteen outpatients who proved to be noncompliant in the follow-up period had higher baseline BPRS "agitation" scores and ROMI-J "no perceived daily benefit" ratings than compliant patients. Sixty-four outpatients who maintained compliance during the follow-up had higher baseline ROMI-J ratings of "fulfillment of life goals" than their noncompliant counterparts. It is important to understand the attitudes of patients with schizophrenia toward drug therapy in order to predict better compliance and provide psychoeducation designed to forestall relapses.

Safety and tolerability of emerging pharmacological treatments for bipolar disorder

OBJECTIVES

Over the past few years numerous new agents have been examined for their efficacy in bipolar disorder (BPD). New antiepileptic agents and atypical antipsychotics currently form the bulk of these emerging agents. As the armamentarium for treating BPD increases, it allows for the possibility of choosing drugs on the basis of their tolerability as well as their efficacy, rather than on efficacy alone.

METHODS

Efficacy data for newer antiepileptic drugs (lamotrigine, topiramate, gabapentin, oxcarbazepine) and atypical antipsychotics (olanzapine, clozapine, risperidone, quetiapine, ziprasidone, aripiprazole) are briefly reviewed. The article focuses on relative safety and tolerability of these agents.

RESULTS

In general, most of these newer agents have better side effect and tolerability profiles than older agents commonly used to treat BPD (lithium, valproate, carbamazepine); however, these must be weighed against efficacy demonstrated to date in randomized, controlled trials. Cognitive impairment is a concern with topiramate, weight gain and risk of diabetes with some of the atypical antipsychotic agents, and rash with lamotrigine.

CONCLUSIONS

Side effects of newer emerging agents for the treatment of BPD can be effectively managed and the risks reduced by instituting practical strategies early in management.

A psychoeducational program for children with ADHD or depression and their families: results from the CMAP feasibility study

For children and adolescents with behavioral and emotional disorders and their families, education about their disorders and the treatments is an essential component of a comprehensive approach to their care. Education can encourage active participation in treatment, enhance adherence to treatment regimens, and provide patients and families with important coping skills. Thus, the Children's Medication Algorithm Project (CMAP) incorporated a psychoeducational program into the medication algorithm created to improve treatment of children with ADHD and/or depression in the Texas public mental health sector. This article describes the process by which a comprehensive educational program was developed in partnership with parents and advocates. The final program is described, as well as a pilot study to examine the feasibility of implementation in four community clinics.

Australian and New Zealand clinical practice guidelines for the treatment of bipolar disorder

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority

METHOD

For these guidelines, the CPG team reviewed the treatment outcome literature (including meta-analyses) and consulted with practitioners and consumers.

TREATMENT RECOMMENDATIONS

This guideline provides evidence-based recommendations for the management of bipolar disorder by phase of illness, that is acute mania, mixed episodes and bipolar depression, and the prophylaxis of such episodes. It specifies the roles of various mood-stabilizing medications and of psychological treatments such as cognitive therapy and psycho-education.

The effects of patient education in lithium therapy on quality of life and compliance

The purpose of this study was to show the effects of education on medication compliance, symptom level and quality of life of outpatients who were being treated with lithium for bipolar disorder. The study was performed comparing a total of 26 patients (14 study and 12 control) who were a patient group in lithium therapy. In the study one group was given a short education program about the disorder and lithium therapy in three sessions. Data were collected from both groups using a medication knowledge form, Brief Symptom Inventory, and WHO Quality of Life Scale before and after the intervention. At the end of 3 months whereas there was no difference seen in the scores of the control group; the study group had an increase in medication knowledge, a decrease in symptom level, an increase in quality of life, and a beginning of more regular medication use. Findings that were obtained show the importance of education about the disorder and medication in increasing the adaptation to society of patients who have bipolar disorder.

[Systemic review of clinical interventions for reducing treatment non-adherence in psychosis]

AIMS

Studies investigating the efficacy of clinical interventions for reducing treatment non-adherence have generated contrasting findings, and treatment non-adherence remains very common in clinical practice. This systematic review was carried out to investigate the efficacy of clinical interventions that community psychiatric services can implement to reduce non-adherence in patients with psychosis.

METHOD

Systematic review of randomised clinical trials, controlled clinical trials and observational studies assessing the efficacy of adherence enhancing interventions.

RESULTS

Forty-seven studies met the inclusion criteria and were included in this systematic review. Data suitable for re-analysis were reported in 24 studies; from the remaining 23 studies, with no data suitable for re-analysis, outcome data were extracted according to what study authors reported. In the group of studies included in the meta-analysis educational and psychotherapeutic interventions were more effective than usual care in reducing patient non-adherence. The remaining 23 studies reported contrasting findings regarding the efficacy of educational strategies. Case management models improved the adherence in half of studies, while other interventions were effective in the majority of studies reported.

CONCLUSIONS

Community psychiatric services can arrange effective clinical interventions, backed by scientific evidence, for reducing patient non-adherence.

Levocetirizine is effective for symptom relief including nasal congestion in adolescent and adult (PAR) sensitized to house dust mites

BACKGROUND

Antihistamines are the most commonly prescribed class of medication for perennial allergic rhinitis (PAR). The primary objective of this study was to determine whether levocetirizine (Xyzal(R)), the active enantiomer of cetirizine, could achieve at least a 50% improvement in PAR symptoms compared to the placebo over the first week of treatment.

METHODS

A total of 294 patients with PAR due to house dust mites were randomized in this 8-week double-blind, placebo-controlled, multicentre trial to receive either levocetirizine 5 mg/day or placebo. Mean Total Four-Symptom Scores (T4SS) (nasal pruritus, ocular pruritus, rhinorrhoea and sneezing) were compared between treatment groups over weeks 1, 4 and 6. All individual symptom scores, including nasal congestion, were also studied.

RESULTS

Levocetirizine showed an 86% improvement in T4SS over the first week of treatment and a 47% improvement over the entire treatment period compared with placebo. Absolute changes from baseline were 3.64 and 2.47 for levocetirizine and placebo, respectively. Individual symptom scores showed statistically significant (P < or = 0.01) differences in favour of levocetirizine for all study time-points. Nasal congestion was unexpectedly significantly improved (P < 0.001). The incidence of reported adverse events was comparable between treatment and placebo group.

CONCLUSIONS

Levocetirizine 5 mg/day is an effective and well-tolerated treatment of PAR. In addition, levocetirizine is effective for the relief of nasal congestion.

Interventions to improve antipsychotic medication adherence: review of recent literature

Antipsychotic nonadherence is an important barrier to the successful treatment of schizophrenia and can lead to clinical and economic burdens. Interventions capable of significantly improving medication adherence in patients with schizophrenia would be beneficial in maximizing treatment outcomes with antipsychotics. This article reviews recent literature reporting interventions designed to improve antipsychotic adherence in patients with schizophrenia. We searched the Medline, Healthstar, and PsycInfo electronic databases for articles published since 1980 on interventions to improve medication adherence in schizophrenia. Twenty-one studies met our selection criteria. In this review, educational, behavioral, affective, or a combination of these approaches to improve adherence were examined. A total of 23 interventions were tested, as 2 studies investigated more than 1 intervention. While study design and adherence measures varied across the trials reviewed, medication adherence was noted to moderately improve with 15 of the 23 interventions tested. Interventions of a purely educational nature were the least successful at improving antipsychotic adherence. The greatest improvement in adherence was seen with interventions employing combinations of educational, behavioral, and affective strategies with which improvements in adherence were noted in 8 out of 12 studies, with additional secondary gains such as: reduced relapse, decreased hospitalization, decreased psychopathology, improved social function, gains in medication knowledge, and improved insight into the need for treatment. Longer interventions and an alliance with therapists also appeared important for successful outcomes. The continuing development and study of successful interventions to improve medication adherence are necessary to maximize the usefulness of pharmacologic treatment of schizophrenia.

Factors associated with patients' knowledge of and attitudes towards treatment with lithium

BACKGROUND

Treatment with lithium is often compromised by poor adherence, by side-effects and by patients' having serum levels outside the therapeutic range. These factors may be affected by patients' knowledge and attitudes towards lithium, and we set out to establish factors associated with knowledge about and attitudes towards lithium among a large representative sample of patients.

METHOD

Patients known to be taking lithium in Grampian during 1995 were surveyed postally during 1998 with the Lithium Knowledge Test (LKT) and the Lithium Attitudes Questionnaire (LAQ). Scores on these measures were analysed against patients' sociodemographic and clinical characteristics by stepwise multiple regression.

RESULTS

Of 742 patients, 411 (55%) completed an LKT and 362 (49%) completed an LAQ. Stepwise multiple regression established that positive attitudes towards lithium on the LAQ were associated with higher serum lithium levels (P=0.005) and with continuing to take lithium (P<0.001). Higher knowledge on the LKT was associated with positive attitudes on the LAQ (P=0.002), with younger age (P<0.001), and with shorter duration of treatment (P=0.01)

LIMITATIONS

The study was retrospective and the response rate was relatively low.

CONCLUSIONS

Education about lithium is likely to be of particular importance in the elderly and 'refresher courses' are advisable for those who have been on lithium for lengthy periods. Interventions which modify attitudes, rather than enhancing knowledge, are likely to be helpful in promoting adherence.

Four-year outcome in non-compliant schizophrenia patients treated with or without home-based ambulatory outpatient care

Non-compliance in neuroleptic maintenance treatment is a major concern in schizophrenia. Home-based outpatient care has been shown both to improve medication compliance and reduce relapse frequency. We analysed the need for hospitalisation, levels of functioning and mortality rate during the de-institutionalisation process in 41 schizophrenia patients with repeated hospitalisations and prolonged history of non-compliance. Eighteen of the patients received ambulatory outpatient care (AOC) after discharge. This treatment procedure focuses on enduring neuroleptic maintenance treatment. One of the hospital nurses takes care of home visits every 2-4 weeks. In the 4-year follow-up, half of the patients in the AOC group did not need hospitalisation at all and the number of days of hospitalisation in the whole group diminished by almost four-fifths compared with the previous 4 years. In the non-AOC group, there was a more limited decrease in the number of days of hospitalisation during the corresponding follow-up period. The mortality rates showed a slight tendency towards a better outcome in the AOC group. There was no change in the levels of functioning in the AOC group. This treatment can be carried out with limited resources. It clearly reduces the need for hospitalisation in a subgroup of schizophrenia patients having problems with compliance and recurrent relapse. The effectiveness of AOC on the mortality rates of schizophrenia patients needs further examination.

Lack of awareness and nonadherence in schizophrenia

This cross-sectional study examines whether lack of awareness of symptoms is a predictor for nonadherence. The study consecutively recruited 134 participants with Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnoses of schizophrenia spectrum disorders at acute psychiatric units. Outcome was measured by a combination of self-reports, utilizing the Rating on Medication Influences and medical records. The univariate analysis showed that homelessness was a predictor for nonadherence (p = .03). The subsequent logistic regression showed that the multidimension symptom lack of awareness score was significantly associated with nonadherence to psychotropic medications (odds ratio = 0.59, 95% Confidence Interval = 0.35, 0.96). Other clinical and demographic variables as well as subjective responses were not significant predictors of nonadherence.

From compliance to concordance: a review of the literature on interventions to enhance compliance with antipsychotic medication

Non-compliance with antipsychotic medication is observed in around 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity. A number of factors influence patient's decisions about taking medication and include awareness of illness, beliefs about treatment and side-effects of medication. A variety of interventions targeted at improving compliance have been tested. Education increases patients' understanding of their illness and treatment but does not improve compliance. However, interventions, such as compliance therapy, based on cognitive-behavioural techniques appear to be effective in enhancing compliance and preventing relapse.

Predictors of noncompliance in males with first-episode schizophrenia, schizophreniform and schizoaffective disorder

PURPOSE

Many factors influencing compliance in schizophrenia have been reported in the literature. Our aim was to assess predictors of noncompliance in male patients with first-episode schizophrenia, schizophreniform and schizoaffective disorder in a naturalistic setting.

SUBJECTS AND METHODS

Fifty-six male patients, discharged from hospital, were included in a 1-year follow-up study. Psychopathological symptoms were assessed with positive and negative syndrome scale at admission and discharge, while extrapyramidal side effects were recorded weekly during hospitalisation using the Simpson-Angus and Barnes akathisia scales. Socio-demographic and some other variables were also recorded.

RESULTS

Thirty patients (53.6%) dropped out of treatment in the first year and 21 of them relapsed. With the Cox survival analysis three predictors of noncompliance were found: diagnosis of schizophrenia versus the other two diagnoses, positive symptoms at admission, and lack of insight at discharge. Discussion. In spite of a specific methodology and selection of only first-episode male patients, the results are in accordance with the findings of other authors. This confirms the universality of noncompliance in psychotic patients.

CONCLUSIONS

First-episode patients have a high dropout rate. However, in compliant patients, the relapse rate was low, and therefore special attention and compliance-promoting interventions in first-episode patients are needed.

Treatment non-adherence in affective disorders

OBJECTIVE

The aim of this paper is to review the prevalence, predictors and methods for improving medication adherence in unipolar and bipolar affective disorders.

METHOD

Studies were identified through Medline and PsycLit searches of English language publications between 1976 and 2001. This was supplemented by a hand search and the inclusion of selected descriptive articles on good clinical practice.

RESULTS

Estimates of medication non-adherence for unipolar and bipolar disorders range from 10 to 60% (median 40%). This prevalence has not changed significantly with the introduction of new medications. There is evidence that attitudes and beliefs are at least as important as side-effects in predicting adherence. The limited number of empirical studies of how to reduce non-adherence offer encouraging evidence that, if recognized, the problem can be overcome.

CONCLUSION

Only 1-2% of all publications on the treatment of affective disorders explore factors associated with medication non-adherence. This is disappointing as research and clinical data highlight the importance of extended courses of medication in improving the long-term prognosis of affective disorders.

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.

An audit of psychiatric case notes in relation to antipsychotic medication and information giving

This paper reports upon a Welsh Office funded "clinical effectiveness" project. The project aimed to produce evidence-based practice guidelines for depot neuroleptic medication. An audit was conducted to establish current practice regarding the provision of illness and treatment specific information to out-patients and their informal carers. Sixty-five patients' case-notes, under the care of a single community mental health team were examined for evidence of the type, nature and frequency of information given to patients receiving typical depot neuroleptic medications. Service guidelines were produced and are presented.

Characteristics of patients with schizophrenia who do not believe they are mentally ill

The purpose of this study was to use a very simple self-report measure to identify patients who did not believe they were mentally ill and describe their characteristics. The study included 177 inpatients and outpatients with schizophrenia. Multivariate regression methods analyzed the relationship between illness belief and sociodemographic, clinical, and attitudinal factors. Thirty-seven percent of subjects did not believe they were mentally ill. Younger age, fewer depressive symptoms, lower perceived medication efficacy, greater satisfaction with current mental health, and less concern about mental illness stigma were associated with not believing one was mentally ill. Outpatients with fewer hospitalizations were less likely to believe they were ill. Inpatients with more hospitalizations were less likely to believe they were ill and had poor medication adherence. Readily identifying patients who do not believe they are mentally ill may be useful to clinicians and policymakers when matching at-risk patients with adherence interventions.

Depot neuroleptics, schizophrenia and the role of the nurse: is practice evidence based? A review of the literature

Nurses are expected to justify their practice with research based evidence. Community psychiatric nurses (CPNs) are under pressure to concentrate more on the 'seriously mentally ill', particularly those with a diagnosis of schizophrenia. Neuroleptic medicines are a recommended therapy in schizophrenia. The administration and monitoring of these drugs is a central part of the CPN's role. The CPN also often assumes an important position as patient advocate in relation to prescribing practices. Neuroleptics are commonly given in depot form to promote compliance, prevent relapse and be of benefit to the patient. This literature review considers the research evidence that these aims are achieved through current practice and reflects on the implications for nursing. In the absence of definitive research work, it may be that important decisions are based on received wisdom rather than research evidence. Whilst the data supporting the use of depots are inconclusive, there is an increasing body of knowledge demonstrating the efficacy of nursing approaches to drug therapy which seek to empower the patient.