Short-term clinical stability and lack of insight are associated with a negative attitude towards antipsychotic treatment at discharge in patients with schizophrenia and bipolar disorder

Comparison of Attitude and Insight Toward Illness Between in Patients with Bipolar I Disorder Manic Episode and Major Depressive Disorder

Background

Studies comparing insight toward illness in patients with bipolar I disorder manic episode and in patients with major depressive disorder are scarce. The aim of this study was to investigate the attitudes and insight of patients with bipolar I disorder in manic episode and in patients with major depressive disorder.

Methods

In total, 86 patients were recruited, including 52 inpatients with bipolar I disorder in manic episodes and 34 inpatients with major depressive disorder. Attitudes toward illness were evaluated using the Self-Appraisal of Illness Questionnaire. Higher Self-Appraisal of Illness Questionnaire scores indicate better awareness and positive attitudes toward one's illness. Insights were assessed using the Insight Scale for Affective Disorders. Higher scores indicate poorer insight. To identify group differences, we used Mann-Whitney U test for statistical analysis.

Results

In the Self-Appraisal of Illness Questionnaire, items 1, 2, 3, 4, 6, 7, 10, 15, and 17 showed significantly lower scores in patients with bipolar I disorder than those with major depressive disorder (P < .05). All 3 subscales (presence/outcome of illness, need for treatment, and worry) of the Self-Appraisal of Illness Questionnaire revealed significantly lower scores in the bipolar I disorder group (P < .05). In the Insight Scale for Affective Disorders, items 3, 4, 12, and 16 showed significantly higher scores in the bipolar I disorder group (P < .05).

Conclusion

Patients with major depressive disorder had significantly more positive attitudes and greater insight than those with bipolar I disorder. Patients with bipolar I disorder are less aware of their symptoms, including changes in mood, speed of mental functioning, and social relationships. The clinicians may integrate the findings into treatment plans for mood disorders.

Relationship of insight to neurocognitive function and risk of recurrence in depression: A naturalistic follow-up study

Introduction

Major depressive disorder (MDD) is a highly recurrent mental illness accompanied by impairment of neurocognitive function. Lack of insight may affect patients’ motivation to seek treatment, resulting in poor clinical outcomes. This study explores the relationship of insight to neurocognitive function and the risk of recurrence of depressive episodes in patients with MDD.

Methods

Demographic, clinical variables, and neurocognitive function measured with Intra-Extra Dimensional Set Shift (IED) from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were collected from 277 patients with MDD. Among them, 141 participants completed a follow-up visit within 1–5 years. Insight was measured using the 17-item Hamilton Depression Rating Scale (HAM-D). To explore the factors associated with recurrence, binary logistic regression models were used.

Results

Patients with MDD, without insight, had significantly higher total and factor scores (anxiety/somatization, weight, retardation, and sleep) on the HAM-D and worse performance in the neurocognition task, compared to those with insight. Furthermore, binary logistic regression revealed that insight and retardation can predict recurrence.

Conclusion

Lack of insight is associated with recurrence and impaired cognitive flexibility in patients with MDD.

Efficacy of Transcranial Direct Current Stimulation to Improve Insight in Patients With Schizophrenia: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND AND HYPOTHESIS

Impaired insight into the illness and its consequences is associated with poor outcomes in schizophrenia. While transcranial direct current stimulation (tDCS) may represent a potentially effective treatment strategy to relieve various symptoms of schizophrenia, its impact on insight remains unclear. To investigate whether tDCS would modulate insight in patients with schizophrenia, we undertook a meta-analysis based on results from previous RCTs that investigated the clinical efficacy of tDCS. We hypothesize that repeated sessions of tDCS will be associated with insight improvement among patients.

STUDY DESIGN

PubMed and ScienceDirect databases were systematically searched to identify RCTs that delivered at least 10 tDCS sessions in patients with schizophrenia. The primary outcome was the change in insight score, assessed by the Positive and Negative Syndrome Scale (PANSS) item G12 following active tDCS sessions as opposed to sham stimulation. Effect sizes were calculated for all studies and pooled using a random-effects model. Meta-regression and subgroup analyses were conducted.

STUDY RESULTS

Thirteen studies (587 patients with schizophrenia) were included. A significant pooled effect size (g) of -0.46 (95% CI [-0.78; -0.14]) in favor of active tDCS was observed. Age and G12 score at baseline were identified as significant moderators, while change in total PANSS score was not significant.

CONCLUSIONS

Ten sessions of active tDCS with either frontotemporoparietal or bifrontal montage may improve insight into the illness in patients with schizophrenia. The effect of this treatment could contribute to the beneficial outcomes observed in patients following stimulation.

Psychometric properties of Drug Attitude Inventory among patients with schizophrenia

Background

The treatment of patients diagnosed with schizophrenia has remained three-fold physical (pharmacological), psychological and social. Furthermore, the need to monitor adherence to the physical aspect of treatment has been a major concern to mental health practitioners as this usually affects the success of psychological and social treatment.

Aim

My study aimed to determine the psychometric properties of Drug Attitude Inventory (DAI) among patients with schizophrenia. The study was carried out at the Neuropsychiatric Hospital, Aro Abeokuta Ogun State and on an average, about 150 patients were seen daily at the outpatient clinic.

Methods

Internal consistency, item-total correlation (the two-way mixed method with absolute agreement) and Cronbach’s alpha were evaluated using an intra-class correlation coefficient (ICC). This instrument’s level of adequacy was determined using factor analysis (principal component analysis with varimax rotation).

Result

Marital status and level of education were significantly associated with adherence. The Cronbach’s alpha was 0.56 and principal components factor analysis with varimax rotation produced a three-factor solution.

Conclusion

My study has shown that the DAI is a valid and reliable instrument and can be used in a clinical setting where there are limitations with time such as the outpatient clinic.

Attitude Towards Drug Therapy in a Community Mental Health Center Evaluated by the Drug Attitude Inventory

INTRODUCTION

Negative attitude towards drug therapy can foster limited adherence to treatment, which remains one of the biggest obstacles for implementing effective treatments, especially long term.

PURPOSES

The purposes of the study were 1) to evaluate the attitude towards drug therapy among a representative sample of patients treated in a community psychiatric service using 30-item Drug Attitude Inventory (DAI-30); 2) to evaluate the DAI-30 dimensions, applying factorial analysis; and 3) to highlight the socio-demographic and clinical variables correlated to DAI-30 score and factors.

METHODS

The DAI was administered, over a 7-month period, to all patients treated in our psychiatric outpatient services who agreed to participate in this study and provided their informed consent. Data were statistically analyzed.

RESULTS

With a response rate of 63.3%, 164 females and 136 males completed the DAI-30 with an average score of 14.24 (±10.46 SD), indicating moderately positive attitude towards drug therapy. The analysis of DAI-30 internal consistency confirmed its reliability (Cronbach's alpha=0.84). Our factorial analysis highlighted three factors: Factor 1 (Cronbach's alpha=0.81), composed of 7 items which indicate positive, trustful attitude; Factor 2 (Cronbach's alpha=0.78), composed of 5 items indicating negative attitude of suspiciousness; and Factor 3 (Cronbach's alpha=0.66), composed of 4 items suggesting defensive and control attitude towards drug therapy.

DISCUSSION

Among the selected variables, "monotherapy" and "total number of hospitalizations" were negatively correlated to the final score of DAI-30, whereas being "married" was positively correlated to it, in a statistically significant way, using the multiple linear regression model. These correlations suggest that positive attitude towards drug therapy could be reinforced by the condition of being married and reduced by relapses with hospitalization, as literature highlighted, and, paradoxically, by a monotherapy, which could suggest a sort of psychological dependence on therapy and, indirectly, on psychiatric service, potentially correlated to the long-term treatments of our patients.

Adherence to Antipsychotic Medication and Quality of Life in Latin-American Patients Diagnosed with Schizophrenia

PURPOSE

The purpose of this study was to describe the association between adherence to antipsychotic medication and quality of life (QoL) in a sample of individuals diagnosed with schizophrenia.

METHODS

Two hundred fifty-three patients were included from three public mental health services from Bolivia, Peru, and Chile. Data were collected using the Drug Attitude Inventory (DAI-10) and the Schizophrenia Quality of Life short-version questionnaire (SQoL-18), which considers 8 dimensions.

RESULTS

Significant associations were found between adherence to antipsychotic medication treatment and QoL (S-QoL-18 index: β = 0.26, p = 0.004; self-esteem: β = 0.37, p = 0.000; and sentimental life: β = 0.20, p = 0.033). Associations of clinical and socio-demographic variables with QoL were identified: severity of psychotic symptoms, awareness of the disease, gender, age, and ethnicity were found to be associated with a lower level of QoL (β from 0.14 -0.56).

CONCLUSION

This study provides evidence of the association between adherence to treatment and quality of life in patients diagnosed with schizophrenia. Therefore, as in developed countries, improving adherence to antipsychotic medication would appear to be an important issue to address to improve patients' QoL in Latin American countries.

Attitude towards Antipsychotic Medications in Patients Diagnosed with Schizophrenia: A Cross-Sectional Study at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia

BACKGROUND

Poor attitude towards antipsychotic drugs is high, and it is a factor for non-adherence to treatment. This increases the risk of relapse, associated healthcare utilization, and costs. This study aimed to assess attitude towards antipsychotic medication among patients with schizophrenia.

OBJECTIVES

The aim of this institution based cross-sectional study was to assess attitude towards antipsychotic medications and associated factors among patients with schizophrenia who attend the outpatient clinics at Amanuel Mental Specialized Hospital, 2018.

METHODS

In a cross-sectional study, 393 schizophrenic patients from Amanuel Mental Specialized Hospital were recruited by a systematic random sampling technique. Drug Attitude Inventory (DAI-10) was used to assess attitude, experience, and belief about antipsychotics. Glasgow antipsychotic side effect scale modified version, positive and negative syndrome scale, and Birch wood's insight scale for psychosis were the instruments used to assess the associated factors. Simple and multiple linear regression analysis models were fitted, and the adjusted unstandardized beta (β) coefficient at 95% confidence interval was used.

RESULTS

The mean score of attitude towards antipsychotic medications was 6.51 with standard deviation (SD) of 2.22. In multiple linear regression, positive symptoms (β= -0.07, 95% CI: (-0.09, -0.05)), negative symptoms (β= -0.04, 95% CI: (-0.06,-0.02)), shorter (≤5 years) duration of illness (β= -0.39, 95% CI: (-0.63, -0.15)), first generation antipsychotics (β = -0.35, 95% CI: (-0.55,-0.14)), having sedation (β= -0.28, 95% CI: (-0.52, -0.02)), and extra-pyramidal side effects (β= -0.34, 95% CI: (-0.59,-0.09)) were factors negatively associated with attitude towards antipsychotic medication treatment. Insight to illness (β= 0.24, 95% CI: (0.20, 0.27) was a factor positively associated with attitude towards antipsychotic medications.

CONCLUSION

The result suggests that the mean score of participants' attitude towards antipsychotic medications was good. Prevention of side effects particularly due to first generation antipsychotics is necessary.

Medication nonadherence in bipolar disorder: a narrative review

A number of effective maintenance medication options exist for bipolar disorder (BD) and these are regarded as the foundation of long-term treatment in BD. However, nonadherence to medication is common in BD. For example, a large data base study in the United States of America (USA) showed that approximately half of patients with BD were nonadherent with lithium and maintenance medications over a 12 month period. Such nonadherence carries a high risk of relapse due to the recurrent nature of the illness and the fact that abrupt cessation of treatment, particularly lithium, may cause rebound depression and mania. Indeed, medication nonadherence in BD is associated with significantly increased risks of relapse, recurrence, hospitalization and suicide attempts and a decreased likelihood of achieving remission and recovery, as well as with higher overall treatment costs. Factors associated with nonadherence include adverse effects of medication, complex medication regimens, negative patient attitudes to medication, poor insight, rapid-cycling BD, comorbid substance misuse and a poor therapeutic alliance. Clinicians should routinely enquire about nonadherence in a nonjudgmental fashion. Potential steps to improve adherence include simple pragmatic strategies related to prescribing including shared decision-making, psychoeducation with a clear focus on adherence, reminders (traditional and digital), potentially using a depot rather than an oral antipsychotic, managing comorbid substance misuse and improving therapeutic alliance. Financial incentives have been shown to improve adherence to depot antipsychotics, but this approach raises ethical issues and its long-term effectiveness is unknown. Often a combination of approaches will be required. The strategies that are adopted need to be patient specific, reflecting that nonadherence has no single cause, and chosen by the patient and clinician working together.

The validity and Reliability of the Turkish Version of Drug Attitude Inventory-10

Introduction

Compliance with drug treatment is an important issue in schizophrenia for which many scales have been devised. Turkish version of the Drug Attitude Inventory is frequently employed due to ease of use and high predictive value, although it is not as accurate as blood level testing.To determine the validity and reliability of the Turkish version of the Drug Attitude Inventory-10.

Methods

Eighty-two schizophrenia patients were included in the study. Subjects were evaluated using Drug Attitude Inventory-10, a Sociodemographic Data Form, Positive and Negative Symptom Scale PANNS, Social Functioning Scale, and Quality of Life Scale for schizophrenia patients.

Results

Reliability analysis revealed Cronbach's α coefficient for internal consistency to be 0.798 and item-total item correlation coefficients to be between 0.420 and 0.647. Test-retest correlation coefficient (r) was 0.809. Construct validity analysis revealed a tri-factorial construct which accounts for 62.68% of variance. Good conformity to single factor construct was found with confirmatory factor analysis.

Conclusion

Turkish version of the Drug Attitude Inventory-10 is valid and reliable for evaluation of schizophrenia patients which makes it suitable for research and clinical settings.

Attitudes toward antipsychotic treatment among patients with bipolar disorders and their clinicians: a systematic review

INTRODUCTION

Antipsychotics are recommended as first-line therapy for acute mania and maintenance treatment of bipolar disorder; however, published literature suggests their real-world use remains limited. Understanding attitudes toward these medications may help identify barriers and inform personalized therapy. This literature review evaluated patient and clinician attitudes toward the use of antipsychotics for treating bipolar disorder.

MATERIALS AND METHODS

A systematic search of the Cochrane Library, Ovid MEDLINE, Embase, and BIOSIS Previews identified English language articles published between January 1, 2000, and June 15, 2016, that reported attitudinal data from patients, health care professionals, or caregivers; treatment decision-making; or patient characteristics that predicted antipsychotic use for bipolar disorder. Results were analyzed descriptively.

RESULTS

Of the 209 references identified, 11 met the inclusion criteria and were evaluated. These articles provided attitudinal information from 1,418 patients with bipolar disorder and 1,282 treating clinicians. Patients' attitudes toward antipsychotics were generally positive. Longer duration of clinical stability was associated with positive attitudes. Implementation of psychoeducational and adherence enhancement strategies could improve patient attitudes. Limited data suggest clinicians' perceptions of antipsychotic efficacy and tolerability may have the greatest impact on their prescribing patterns. Because the current real-world evidence base is inadequate, clinician attitudes may reflect a relative lack of experience using antipsychotics in patients with bipolar disorder.

CONCLUSION

Although data are very limited, perceived tolerability and efficacy concerns shape both patient and clinician attitudes toward use of antipsychotic drugs in bipolar disorder. Additional studies are warranted.

Medication nonadherence among South American patients with schizophrenia

OBJECTIVE

The objective of this research was to quantify nonadherence to medication and explore the determinants of nonadherence in patients diagnosed with schizophrenia (SZ) from three countries in Latin America (Bolivia, Peru, and Chile).

METHODS

This study was conducted in public mental health centers in Bolivia, Peru, and Chile. The data collected included drug attitude inventory (DAI-10), sociodemographic information, and clinical and treatment characteristics of patients with SZ. Multivariate analysis with multiple linear regression was then performed to identify variables that were potentially associated with the DAI score (dependent variable).

RESULTS

Two hundred and fifty-three patients diagnosed with SZ participated in the study and 247 fully completed the DAI-10. In the multivariate analysis, medication nonadherence was associated with being a woman (β=-0.16, p=0.029), younger age (β=0.17, p=0.020), younger age at onset of disease (β=-0.17, p=0.019), and lower insight (β=-0.30, p<0.001).

CONCLUSION

Being a female, younger age, younger age at onset of disease, and lower insight were the main features associated with nonadherence. If future longitudinal studies confirm these findings, these factors should not be neglected in Latin American mental health public policies to address the problem of nonadherence.

Treatment-adherence in bipolar disorder: A patient-centred approach

About half of the patients diagnosed with bipolar disorder (BD) become non-adherent during long-term treatment, a rate largely similar to other chronic illnesses and one that has remained unchanged over the years. Non-adherence in BD is a complex phenomenon determined by a multitude of influences. However, there is considerable uncertainty about the key determinants of non-adherence in BD. Initial research on non-adherence in BD mostly limited itself to examining demographic, clinical and medication-related factors impacting adherence. However, because of inconsistent results and failure of these studies to address the complexities of adherence behaviour, demographic and illness-related factors were alone unable to explain or predict non-adherence in BD. This prompted a shift to a more patient-centred approach of viewing non-adherence. The central element of this approach includes an emphasis on patients’ decisions regarding their own treatment based on their personal beliefs, life circumstances and their perceptions of benefits and disadvantages of treatment. Patients’ decision-making processes are influenced by the nature of their relationship with clinicians and the health-care system and by people in their immediate environment. The primacy of the patient’s perspective on non-adherence is in keeping with the current theoretical models and concordance-based approaches to adherence behaviour in BD. Research over the past two decades has further endorsed the critical role of patients’ attitudes and beliefs regarding medications, the importance of a collaborative treatment-alliance, the influence of the family, and the significance of other patient-related factors such as knowledge, stigma, patient satisfaction and access to treatment in determining non-adherence in BD. Though simply moving from an illness-centred to a patient-centred approach is unlikely to solve the problem of non-adherence in BD, such an approach is more likely to lead to a better understanding of non-adherence and more likely to yield effective solutions to tackle this common and distressing problem afflicting patients with BD.

Effect of a Multi-Dimensional and Inter-Sectoral Intervention on the Adherence of Psychiatric Patients

BACKGROUND

In psychiatry, hospital stays and transitions to the ambulatory sector are susceptible to major changes in drug therapy that lead to complex medication regimens and common non-adherence among psychiatric patients. A multi-dimensional and inter-sectoral intervention is hypothesized to improve the adherence of psychiatric patients to their pharmacotherapy.

METHODS

269 patients from a German university hospital were included in a prospective, open, clinical trial with consecutive control and intervention groups. Control patients (09/2012-03/2013) received usual care, whereas intervention patients (05/2013-12/2013) underwent a program to enhance adherence during their stay and up to three months after discharge. The program consisted of therapy simplification and individualized patient education (multi-dimensional component) during the stay and at discharge, as well as subsequent phone calls after discharge (inter-sectoral component). Adherence was measured by the "Medication Adherence Report Scale" (MARS) and the "Drug Attitude Inventory" (DAI).

RESULTS

The improvement in the MARS score between admission and three months after discharge was 1.33 points (95% CI: 0.73-1.93) higher in the intervention group compared to controls. In addition, the DAI score improved 1.93 points (95% CI: 1.15-2.72) more for intervention patients.

CONCLUSION

These two findings indicate significantly higher medication adherence following the investigated multi-dimensional and inter-sectoral program.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00006358.

Relationship of insight with medication adherence and the impact on outcomes in patients with schizophrenia and bipolar disorder: results from a 1-year European outpatient observational study

BACKGROUND

Many patients with schizophrenia and bipolar disorder have impaired insight and low medication adherence. The aim of this post hoc analysis was to explore the relationship between insight and medication adherence.

METHODS

We included 903 patients with schizophrenia or bipolar disorder who participated in an observational study conducted in Europe on the outcomes of patients treated with two oral formulations of olanzapine over a 1-year period. Evaluations included Clinical Global Impression (CGI), Global Assessment of Functioning (GAF), insight (Scale to Assess Unawareness of Mental Disorder, SUMD) medication adherence (Medication Adherence Rating Scale, MARS), and therapeutic alliance (Working Alliance Inventory, WAI).

RESULTS

Medication adherence was higher in bipolar patients (mean MARS score (SD) 6.5 (2.8) versus 5.8 (2.7) in schizophrenia; p < 0.001). Patients with schizophrenia had lower insight (i.e., SUMD item 1, unawareness of mental disorder, mean (SD) of 2.5 (1.3) in schizophrenia versus 1.9 (1.2) in bipolar, p < 0.001). Better insight was associated with higher adherence (Spearman Correlation Coefficient, SCC, ranging from 0.39 to 0.49 for the three SUMD general items, p < 0.0001 in all cases). Higher insight was related to a stronger therapeutic alliance (SCC ranging from 0.38 to 0.48, p < 0.0001). A path analysis revealed a positive impact of insight on adherence and alliance and that stronger alliance was related to lower clinical severity (lower CGI score).

CONCLUSION

Insight and adherence were found to be closely related. Insight impacts on the therapeutic alliance with mental health professionals. These factors are associated to treatment outcomes.

Attitudes toward psychotropic medications among patients with chronic psychiatric disorders and their family caregivers

AIM

To examine attitudes towards psychotropic medications among patients with chronic psychiatric disorders as well as their family caregivers by using factor analysis.

MATERIALS AND METHODS

The study included 200 patients and their family caregivers with chronic psychiatric disorders who are attending the psychiatry outpatient services. A self-designed 18-item self-rated questionnaire was used to evaluate the attitude toward psychotropics and factor analysis was done to study the different models of attitudes.

RESULTS

In general both patients and caregivers had positive attitude toward the psychotropic medications and there was no significant difference between the patients and caregivers on the various items of the questionnaire assessing the attitude. Factor analysis of the questionnaire indicated that either two-factor or four-factor models explained the attitude of the patients and caregivers. In the two-factor model there was one positive and one negative attitude factor, whereas the four-factor model comprised of two positive and two negative attitude factors. The four-factor model of attitudes provided a more comprehensive solution to how attitudes might be formed among patients and their family caregivers. Factors one and four in the four-factor solution still reflected positive attitudes, but appeared to portray a risk-benefit approach, in which benefits such as the efficacy of psychotropic medications in treating mental illnesses and preventing relapse, and medications being better than other options were being contrasted with the risks of side effects and permanent damage or harm.

CONCLUSION

Attitudes of patients with chronic psychiatric disorders and their caregivers toward psychotropic medications appear to be shaped by factors such as perceived efficacy or benefit from medicines, the necessity for taking treatment and concerns such as side effects, harm or expense.

Suboptimal treatment adherence in bipolar disorder: impact on clinical outcomes and functioning

BACKGROUND

The primary aim of this study was to assess drug treatment adherence in patients with bipolar disorder and to identify factors associated with adherence. The secondary aim was to analyze the impact of suboptimal adherence on clinical and functional outcomes.

METHODS

A cross-sectional study was conducted in a sample of outpatients receiving an oral antipsychotic drug. Medication adherence was assessed combining the 10-item Drug Attitude Inventory, the Morisky Green Adherence Questionnaire, and the Compliance Rating Scale. Logistic regression was used to determine significant variables associated with suboptimal adherence to medication.

RESULTS

Three hundred and three patients were enrolled into the study. The mean age was 45.9 ± 12.8 years, and 59.7% were females. Sixty-nine percent of patients showed suboptimal adherence. Disease severity and functioning were significantly worse in the suboptimal group than in the adherent group. Multivariate analysis showed depressive polarity of the last acute episode, presence of subsyndromal symptoms, and substance abuse/dependence to be significantly associated with suboptimal treatment adherence (odds ratios 3.41, 2.13, and 1.95, respectively).

CONCLUSION

A high prevalence of nonadherence was found in an outpatient sample with bipolar disorder. Identification of factors related to treatment adherence would give clinicians the opportunity to select more adequately patients who are eligible for potential adherence-focused interventions.