Understanding and Managing Treatment Adherence in Schizophrenia

Schizophrenia and medication adherence: Associated factors

BACKGROUND

Schizophrenia is a chronic condition that requiring maintenance treatment with antipsychotic medication. Medication adherence is essential to improve the symptoms of this health problem reduce relapses and readmissions and achieve treatment goals. The rate of challenges associated with medication adherence in schizophrenia is reported to be 26.5-85.1 %.

PURPOSE

This study was conducted to determine factors associated with medication adherence in individuals diagnosed with schizophrenia.

METHODS

A descriptive correlational research design was used. The study was completed with a total of 162 participants diagnosed with schizophrenia, between February-June 2021, at a Community Mental Health Center. Regression analysis (Model: enter and stepwise) was used to determine associated factors.

RESULTS

The mean medication adherence score of individual diagnosed with schizophrenia indicated that more than half of the participants (52 %) had poor medication adherence. In individual diagnosed with schizophrenia, medication attitudes, level of internalized stigma, the status of regular attendance to appointments, belief in recovery, and using medicines as prescribed were complicating factors for medication adherence (p < 0.05).

CONCLUSIONS

Medication adherence in individuals with diagnosed schizophrenia may be multifactorial. Mental health professionals should consider associated factors and implement a personalized treatment plan in this direction for strengthening adherence to medication treatment.

Point of care assay for blood aripiprazole concentrations: development, validation and utility

BACKGROUND

The antipsychotic aripiprazole is often used in the treatment of first-episode psychosis. Measuring aripiprazole blood levels provides an objective measure of treatment adherence, but this currently involves taking a venous blood sample and sending to a laboratory for analysis.

AIMS

To detail the development, validation and utility of a new point of care (POC) test for finger-stick capillary blood concentrations of aripiprazole.

METHOD

Analytical performance (sensitivity, precision, recovery and linearity) of the assay were established using spiked whole blood and control samples of varying aripiprazole concentration. Assay validation was performed over a 14-month period starting in July 2021. Eligible patients were asked to provide a finger-stick capillary sample in addition to their usual venous blood sample. Capillary blood samples were tested by the MyCare™ Insite POC analyser, which provided measurement of aripiprazole concentration in 6 min, and the venous blood sample was tested by the standard laboratory method.

RESULTS

A total of 101 patients agreed to measurements by the two methods. Venous blood aripiprazole concentrations as assessed by the laboratory method ranged from 17 to 909 ng/mL, and from 1 to 791 ng/mL using POC testing. The correlation coefficient between the two methods (r) was 0.96 and there was minimal bias (slope 0.91, intercept 4 ng/ml).

CONCLUSIONS

The MyCare Insite POC analyser is sufficiently accurate and reliable for clinical use. The availability of this technology will improve the assessment of adherence to aripiprazole and the optimising of aripiprazole dosing.

The effect of insight, loneliness, and hope levels on medication adherence in patients with schizophrenia

PURPOSE

It is important to investigate the negative factors affecting medication compliance to continue the treatment of schizophrenia.

DESIGN AND METHODS

In this descriptive and analytical study, the effects of insight, loneliness, and hope levels on medication adherence in 202 patients with schizophrenia were studied.

FINDINGS

The correlation was positive between medication adherence and insight, negative between medication adherence and loneliness, and no correlation between medication adherence and hope. A 1-point increase in insight scores increased medication adherence 1.226 times and a 1-point increase in loneliness scores decreased medication adherence 0.946 times. Medication adherence was 0.499 times lower in nonsmokers compared to smokers.

PRACTICE IMPLICATIONS

Further studies on patients with schizophrenia should be conducted to evaluate factors affecting medication adherence and preventing smoking in schizophrenia.

Efficacy of long-acting injectable versus oral antipsychotic drugs in early psychosis: A systematic review and meta-analysis

AIM

Long-acting injectable antipsychotic drugs (LAIs) are often used as an alternative to oral antipsychotics (OAPs) in individuals with psychosis who demonstrate poor medication adherence. Previous meta-analyses have found mixed results on the efficacy of LAIs, compared to OAPs, in patients with psychotic disorders. The objective of this meta-analysis was to compare the effectiveness of using LAIs versus OAPs in the early stages of psychosis.

METHODS

Major electronic databases were used to search for any studies examining the comparative effectiveness (i.e., relapse, adherence, hospitalization, and all-cause discontinuation) of any LAIs versus OAPs in early stages of psychosis. Studies published up to 6 June, 2019 were included and no language restriction was applied. Inclusion criteria were a diagnosis of schizophrenia or related disorder, where patients were in their first episode or had a duration of illness ≤5 years. Data were analysed using a random-effects model.

RESULTS

Fifteen studies (n = 10 584) were included, of which were 7 RCTs, 7 observational studies, and 1 post-hoc analysis. We found that LAIs provided advantages over OAPs in terms of relapse rates. No significant differences were found between LAI and OAP groups in terms of all-cause discontinuation, hospitalization, and adherence rates. However, considering only RCTs revealed advantages of LAIs over OAPs in terms of hospitalization rates.

CONCLUSIONS

LAIs may provide benefits over OAPs with respect to reducing relapse and hospitalization rates in early psychosis patients. There is a need for larger and better-designed studies comparing OAPs and LAIs specifically in early psychosis patients.

The Disease Recovery Evaluation and Modification (DREaM) study: Effectiveness of paliperidone palmitate versus oral antipsychotics in patients with recent-onset schizophrenia or schizophreniform disorder

We report primary results of the Disease Recovery Evaluation and Modification (DREaM) study, a randomized, open-label, delayed-start trial designed to compare the effectiveness of paliperidone palmitate (PP) versus oral antipsychotics (OAP) in delaying time to first treatment failure (TtFTF) in participants with recent-onset schizophrenia or schizophreniform disorder. DREaM included: Part I, 2-month oral run-in; Part II, 9-month disease progression phase (PP or OAP); Part III, 9 months of additional treatment (PP/PP; OAP rerandomized: OAP/OAP or OAP/PP). PP/PP and OAP/OAP comprised the 18-month extended disease progression (EDP) analysis. A total of 235 participants were randomized to PP (n = 78) or OAP (n = 157) in Part II. No statistically significant differences in TF between treatment groups were identified during Part II (PP 29.5%, OAP 24.8%; P = 0.377), Part III (PP/PP 14.3%, OAP/PP 15.8%, OAP/OAP 28.6%; P = 0.067) or the EDP analysis (PP/PP 28.6%, OAP/OAP 44.4%; NNT = 6; P = 0.080). Using a modified definition of TF excluding treatment supplementation with another antipsychotic, a common approach to managing dose adjustments, significant differences were observed between treatment groups in Part III (PP/PP 4.1%, OAP/PP 14.0%, OAP/OAP 27.0%; P = 0.002) and EDP (PP/PP 14.3%, OAP/OAP 42.9%; P = 0.001). Safety results were consistent with the known safety profile of PP. Although significant treatment differences were not observed during the first 9 months of DREaM, numerical differences favoring PP emerged in the last 9 months and significant differences were observed when TF criteria were limited to their most impactful components. These results highlight the potential benefit of initiating PP early in the course of schizophrenia and provide valuable insights for future clinical trials in recent-onset schizophrenia or schizophreniform disorder. Clinicaltrials.gov identifier: NCT02431702.

Early intervention services, patterns of prescription and rates of discontinuation of antipsychotic treatment in first-episode psychosis

AIMS

Non-compliance is still an important problem in psychotic patients. Although antipsychotic (AP) treatment leads to a decrease in psychotic relapses, there are no clear recommendations about how long treatment should be maintained after first-episode psychosis (FEP) and no indication of the rates and causes of treatment withdrawal in this group.

METHODS

We evaluated a large sample of patients with FEP for 2 years to compare the time to all-cause treatment discontinuation of AP drugs and the time to the first relapse. We collected the sociodemographic and psychopathological characteristics of the sample. The number of relapses was also recorded.

RESULTS

A total of 310 FEP patients were assessed across seven early intervention teams (mean age = 30.2 years; SD = 11.2). The most prevalent diagnosis at baseline was psychotic disorder not otherwise specified (36.1%), and the most commonly used APs were risperidone (26.5%) and olanzapine (18.7%). A lack of efficacy was the most frequent reason for the withdrawal of the first AP prescribed, followed by non-compliance. There were no differences in the relapse rates between different APs. Patients treated with long-acting injectable (LAI) APs presented less disengagement from services than patients treated with oral APs.

CONCLUSIONS

Although there were no differences between the different APs in terms of relapse rates, LAIs had higher retention rates than oral APs in early intervention services. Compliance is still an important issue in Psychiatry, so clinicians should use different strategies to encourage it, such as the use of LAI treatments.

Effects of Mindfulness-Based Cognitive Therapy on Stigma in Female Patients With Schizophrenia

Mindfulness-based cognitive therapy (MBCT) has been increasingly recognized as effective in different mental illnesses, but these effects are limited in schizophrenia. For patients with schizophrenia, stigma is one of the most negative factors that affects treatment, rehabilitation and social function. This research aimed to determine the effects of MBCT on stigma in patients with schizophrenia. In total, 62 inpatients with schizophrenia were recruited and randomly assigned to the experimental group or control group. The experimental group received an 8-week MBCT intervention, and the control group were treated as usual. Link's Stigma Scales (with three subscales, including perceived devaluation-discrimination (PDD), stigma-coping orientation, and stigma-related feeling), Five Facet Mindfulness Questionnaire (FFMQ), and Insight and Treatment Attitudes Questionnaire (ITAQ) were used to collect data before and after intervention. After intervention, the post-test score of PDD, stigma-coping orientation, FFMQ, and ITAQ were significantly different between the experimental group and the control group. In the experimental group, the PDD and stigma-coping orientation scores significantly decreased, and FFMQ and ITAQ scores increased remarkably (P < 0.05). In addition, correlation analysis revealed a significant negative correlation between mindfulness and stigma. MBCT was effective in reducing stigma in patients with schizophrenia, which mainly manifested as changes in the patients' perception of stigma as well as the withdrawal and avoidance caused by schizophrenia. Enhancing mindfulness will help reduce the stigma level. MBCT is worthy of promotion and application in patients with schizophrenia.

FACTORS ASSOCIATED WITH DEPRESSION IN PATIENTS WITH SCHIZOPHRENIA

The aim of this study was to analyze risk factors present in schizophrenic patients with depressive symptomatology. The sample comprised of 76 respondents diagnosed with schizophrenia. In the study, we used the Positive and Negative Syndrome Scale (PANSS) and Calgary Depression Scale for Schizophrenia. The prevalence of depression was estimated to be 30%. The mean scores on the negative subscale of the PANSS were significantly higher in patients with schizophrenia and depression compared to control group (U=3.64, p=0.00), and so were those on the General Psychopathology Scale (U=4.91, p=0.00). Socio-demographic factors were identified as important factors (p<0.05). Personal and environmental factors such as loneliness, immediate social environment, social support and isolation were statistically significantly different between the groups (p<0.05). There was a correlation of poor compliance with psycho-pharmacotherapy, increased number of hospitalizations and shorter remission period with the severity of clinical presentation (p<0.05). Since the presence of these factors is associated with depression in schizophrenia, their early detection in clinical practice is vital to ensure timely prevention of the development of depressive symptomatology.

Monitoring and improving antipsychotic adherence in outpatient forensic diversion programs

Outpatient diversion programs present an opportunity for severely mentally ill defendants to receive psychiatric treatment and have alleged offenses dismissed by the court. Moreover, the successful completion of pretrial diversion is associated with fewer post-program arrest and jail days. The target patient population for such programs is typically people with schizophrenia spectrum disorders, but the care of such patients in outpatient settings presents challenges for monitoring treatment fidelity, specifically antipsychotic adherence, as low adherence rates are associated with increased rates of recidivism. Presented here is a review of evidence-based strategies that must be employed to track antipsychotic adherence in outpatient diversion programs, including pill counts, use of long-acting injectable antipsychotics, and determination of plasma antipsychotic levels to assess adherence and the adequacy of antipsychotic treatment. Antipsychotic therapy remains the foundation of schizophrenia treatment, but only through the use of all available modalities can clinicians maximize the odds that schizophrenia patients in pretrial diversion maintain psychiatric stability and successfully complete mental health court mandates.

Attitude and perceptions of patients towards long acting depot injections (LAIs)

BACKGROUND

Despite the well-established efficacy of the long acting depot injectable (LAIs) antipsychotics, these are significantly underused and underutilized by the mental health professionals, with a belief that patients will not accept the same.

AIMS & OBJECTIVES

To explore the acceptability and perception of patients towards various psychiatric treatments, with specific focus on LAIs. Additionally the study aimed to compare the acceptability of various types of treatments including LAIs between patients with severe mental disorders (Psychotic disorders and Bipolar disorder) and those with Common mental disorders (Anxiety, neurotic and depressive disorders).

METHODOLOGY

A self-designed semi-structured questionnaire was used to evaluate the preferred treatment options of all the new patients attending the psychiatry outpatient clinic of a tertiary care hospital. Depending on the response, they were further probed for the reasons for accepting or rejecting the LAIs.

RESULTS

2659 patients were interviewed who were divided into two groups (Group I - 321 subjects with psychotic disorders and 120 subjects with bipolar affective disorder (BPAD) and Group II - 2218 subjects with neurotic, stress-related and unipolar depressive disorders). More than three-fourth (78.8%) of the participants in the whole study sample opted for tablets only as their first preferred choice and injectables were opted by about 5% of the participants only, with no significant difference between the 2 groups. After being explained about LAIs, one fourth of the participants (24.9%) reported that they may consider LAIs, without any significant difference between the 2 groups. Among those who refused to take LAIs even after explanation, the commonly reported reasons were difficulty in visiting hospital frequently for the injectables (41.69%), injectables being painful (19.41%), fear of injections (13.96%), no need to take LAIs (12.45%) and preference to take some other types of medicines (8.52%).

CONCLUSIONS

Considering the fact that LAIs are highly underused in patients with severe mental disorders and there is lack of awareness about LAIs among patients with severe mental disorders, the present study findings suggest that there is reasonable level of acceptance of LAIs among patients with severe mental disorders when explained about the same.