Medication adherence in schizophrenia: factors influencing adherence and consequences of nonadherence, a systematic literature review

This analysis assessed rates of medication adherence and predictors of nonadherence and hospitalization among patients treated with long-acting injectable and oral antipsychotic therapies. Data were from a retrospective analysis of Florida Medicaid recipients with schizophrenic disorder (ICD-9-CM code 295.XX) who received a prescription for an antipsychotic between July 1, 2004, and June 30, 2005. Patients were required to have filled one additional antipsychotic prescription during follow-up. Adherence measures included medication possession ratio (MPR), medication persistence, medication consistency, and maximum gap in treatment. Multivariate logistic regression models identified predictors of nonadherence and hospitalization. Patients were considered adherent if they had an MPR ≥ .8. A total of 12,032 patients met selection criteria. The mean ± SD MPR was .79 ± .23, medication persistence was 94.1% ± 16.4%, medication consistency was 83.3% ± 16.4%, and the maximum gap in treatment was 29.7 ± 41.4 days. Thirty-seven percent of patients were hospitalized for any cause, and 32% had a psychiatric hospitalization. Predictors of nonadherence included newly starting treatment; younger age; a substance abuse diagnosis; use of a mood stabilizer, antidepressant, anxiolytic, or anticholinergic; and receipt of long-acting first-generation antipsychotics. Receipt of long-acting second-generation therapy or receipt of both first- and second-generation medications was associated with lower likelihood of nonadherence. Predictors of hospitalization risk included a diagnosis of other psychoses or substance abuse, anticholinergic use, and nonadherence to therapy. Results document rates of antipsychotic adherence and predictors of nonadherence and hospitalization. Findings may be useful to health plan administrators, formulary decision makers, and physicians.

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Interventions to improve adherence to antipsychotic medication are needed. The aims of the current study were to identify the most common barriers to medication adherence in a cohort of patients receiving outpatient and inpatient treatment for an acute exacerbation of schizophrenia, compare clinical and demographic characteristics of patients with lower versus higher numbers of barriers, and characterize patients most likely to be nonadherent to antipsychotic medication. The present study analyzed data collected during the Schizophrenia Guidelines Project (SGP), a multisite study of strategies to implement practice guidelines that was funded by the U.S. Department of Veterans Affairs and conducted from March 1999 to October 2000. Nurse coordinators had conducted clinical assessments and performed an intervention designed to improve medication adherence by addressing barriers to adherence. Data on patient symptoms, functioning, and side effects had been obtained using the Positive and Negative Syndrome Scale (PANSS), the Schizophrenia Outcomes Module, the Medical Outcomes Study 36-item Short-Form Health Survey, and the Barnes Akathisia Scale (BAS). Administrative data were used to identify patients with an ICD-9 code for schizophrenia. A total of 153 patients who met this criterion and participated in the intervention arm of the SGP had complete data available for analysis in the current study. The most common patient-reported barriers were related to the stigma of taking medications, adverse drug reactions, forgetfulness, and lack of social support. Bivariate analysis showed that patients with high barriers were significantly more likely to be nonadherent (p < or =.02), to have problems with alcohol or drug use (p =.02), to have higher PANSS total scores (p =.03), and to have higher mean BAS scores (p =.02). Logistic regression showed that lower patient education level (odds ratio [OR] = 3.95, p =.02), substance abuse (OR = 3.24, p =.01), high PANSS total scores (OR = 1.02, p =.05), and high barriers (OR = 2.3, p =.05) were significantly associated with the probability of nonadherence. It may be possible to identify patients most likely to benefit from adherence intervention. The data presented here will help to inform future research of clinical interventions to improve medication adherence in schizophrenia and help to stimulate further work in this area.

Background: Nonadherence to treatment is a recognized problem and the most challenging aspect of treatment, particularly in first-episode schizophrenia (FES). We aimed to identify a set of individuals in the social milieu of patients as opinion makers who play significant role in influencing treatment-seeking behavior in patients with FES. Materials and Methods: Patients with a diagnosis of schizophrenia (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), first episode, were administered with a 20 items semi-structured questionnaire to identify the individuals and their role in treatment-seeking behavior of patients with FES. Results: A total of 72 patients were enrolled in the study. The mean age of the sample was 29 years (standard deviation [SD] ±7.35), and the mean duration of illness was 9.2 (SD ± 0.58) months. Our study shows that apart from treating psychiatrists, patient's family members and relatives play a crucial role in influencing treatment-seeking behavior such as treatment commencement, drug dose, formulation, place of treatment, etc., A large number of patients went to faith healers on the advice of family members (34.7%) and also followed the advice of family members regarding the duration of treatment (63.3%) as well as discontinuing treatment (63.3%). Conclusion: The index study concludes the role of family members/relatives as opinion makers in the social milieu of patients with FES in influencing treatment-related decisions and affecting adherence to treatment.

Impact of sociodemographic factors and depression on medication adherence in schizophrenia: Cross sectional study in Morocco

ObjectiveAlthough various clinical factors that affect medication adherence in schizophrenia have been studied, the role of the therapeutic alliance has not been studied in detail. Accordingly, we investigated the association between medication adherence and therapeutic alliance in patients with schizophrenia treated in a community outpatient clinic in Korea.MethodsIn this cross-sectional study, 81 outpatients who met the DSM-IV-TR criteria for schizophrenia were analyzed. Therapeutic alliance was measured via patient-self-report questionnaires consisting of 12 questions, which evaluate both “affective bond” and “collaborative bond” of alliance. We investigated the relationship between medication adherence and therapeutic alliance through correlation and regression analyses.ResultsOverall therapeutic alliance was weakly associated with medication adherence (r=0.268, p<0.05). Among two factors of therapeutic alliance, “affective bond” was associated with adherence (r=0.302, p<0.05), but collaborative was not. Regression analysis showed that therapeutic alliance significantly predicted medication adherence even after adjustment for duration of treatment, insight, and symptom severity.ConclusionMaintaining a favorable therapeutic alliance is associated with medication adherence in schizophrenia. Further, treating patients in a frank and genuine manner might be important to improve adherence.

To compare levels of social isolation in aging veterans with and without the human immunodeficiency virus (HIV) and determine associations with hospital admission and mortality. Longitudinal data analysis. The Veterans Aging Cohort Study (VACS), at eight VA Medical Centers nationally. Veterans aged 55 and older enrolled in VACS from 2002 to 2008 (N = 1,836). A Social Isolation Score (SIS) was created using baseline survey responses about relationship status; number of friends and family and frequency of visits; and involvement in volunteer work, religious or self-help groups, and other community activities. Scores were compared according to age and HIV status, and multivariable regression was used to assess effects of SIS on hospital admission and all-cause mortality. Mean SIS was higher for HIV-positive (HIV+) individuals, with increasing difference according to age (P = .01 for trend). Social isolation was also more prevalent for HIV+ (59%) than uninfected participants (51%, P < .001). In multivariable regression analysis of HIV+ and uninfected groups combined, adjusted for demographic and clinical features, isolation was independently associated with greater risk of incident hospitalization (hazard rate (HR) = 1.25, 95% confidence interval (CI) = 1.09-1.42) and risk of all-cause mortality (HR=1.28, 95% CI = 1.06-1.54). Risk estimates calculated for HIV+ and uninfected groups separately were not significantly different. Social isolation is associated with greater risk of hospitalization and death in HIV+ and uninfected older veterans. Despite similar effects in both groups, the population-level effect of social isolation may be greater in those who are HIV+ because of the higher prevalence of social isolation, particularly in the oldest individuals.

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Antipsychotic medications provide the foundation for treatment of acute exacerbations as well as relapse prevention in patients with schizophrenia as demonstrated by rigorous placebo-controlled trials. However, despite their proven effectiveness, poor adherence to prescribed antipsychotic regimens remains the most important driver of suboptimal clinical outcomes in this population. This paper reviews the magnitude of the problem of medication non-adherence in patients with schizophrenia and the various factors that contribute to non-adherence, with particular emphasis on factors related to antipsychotic medications. The profile of the latest atypical antipsychotic, paliperidone extended-release (ER) tablets, is then reviewed and the implications of its unique pharmacokinetic profile for adherence in this patient population are discussed.

Attitude toward antipsychotic medication is considered as one of the main predictors for medication adherence in schizophrenia. The present non-interventional cross-sectional study aims to explore the associations between attitudes toward antipsychotic medication, insight and other clinical variables in outpatients with schizophrenia. Attitudes toward antipsychotic medication, clinical and social variables, sociodemographic and illness-related characteristics were assessed via a set of semi-structured clinical interviews and self-rating scales in a total of 226 patients with schizophrenia on a long-term antipsychotic treatment in community based settings. The associations between attitudes toward medication and severity of psychopathology, insight and medication side effects were examined. The greater hospitalization rate in the previous year was associated with more severe psychopathology at the time of the study, more pronounced side effects of the therapy and lack of insight. The lack of insight, the presence of more severe negative and depressive symptoms and disease duration less than 5 years correlated significantly with negative attitudes toward antipsychotic medication. The severity of medication side effects was not associated with the drug attitudes. Psychoeducational and psychotherapeutical interventions, along with pharmacotherapy, can be beneficial in forming positive attitudes toward medication and improving medication adherence in schizophrenia, especially in patients with a short duration of the disease.

PurposeThe purpose of this paper is to develop an understanding of the experience of secure care from the patients’ perspective.Design/methodology/approachA systematic review of qualitative literature was conducted. The data was sourced from the electronic databases: PsychINFO, CINAHL, Medline and the Web of Science Core Collection using pre-defined search terms. A total of 17 studies, conducted in various countries worldwide and covering high, medium and low secure inpatient settings, were included for review. The analysis involved integrating findings from across the literature and was guided by thematic synthesis.FindingsA total of eight themes were generated from the data, three of which provided an understanding of the experience of forensic secure care, and the remaining five themes provided an understanding of the factors which may influence the experience of secure care.Practical implicationsDeveloping understanding of patient experience can lead to service improvements, potentially impacting patients’ motivation and engagement and thus reducing admission times, potential recalls and recidivism.Originality/valueTo the best of the authors’ knowledge, this is the first systematic review to date to exclusively explore the broad topic of the patient experience of secure mental health care.

Although nonadherence with the antipsychotic medication regimen is a common barrier to the effective treatment for schizophrenia, knowledge is limited about how to improve medication adherence. This systematic literature review examined psychosocial interventions for improving medication adherence, focusing on promising initiatives, reasonable standards for conducting research in this area, and implications for clinical practice. Studies were identified by computerized searches of MEDLINE and PsychLIT for the years between 1980 and 2000 and by manual searches of relevant bibliographies and conference proceedings. Key articles were summarized. Thirteen (33%) of 39 identified studies reported significant intervention effects. Although interventions and family therapy programs relying on psychoeducation were common in clinical practice, they were typically ineffective. Concrete problem solving or motivational techniques were common features of successful programs. Interventions targeted specifically to problems of nonadherence were more likely to be effective (55%) than were more broadly based treatment interventions (26%). One-half (four of eight) of the successful interventions not specifically focused on nonadherence involved an array of supportive and rehabilitative community-based services. Psychoeducational interventions without accompanying behavioral components and supportive services are not likely to be effective in improving medication adherence in schizophrenia. Models of community care such as assertive community treatment and interventions based on principles of motivational interviewing are promising. Providing patients with concrete instructions and problem-solving strategies, such as reminders, self-monitoring tools, cues, and reinforcements, is useful. Problems in adherence are recurring, and booster sessions are needed to reinforce and consolidate gains.

To the Editor: Indigenous people face challenges that may make them more sensitive to extreme temperatures. These include poor health, inadequate infrastructure, and poverty.1 Few studies have examined the effects of extreme temperatures on Indigenous people2 or have considered the possible role of body mass in sensitivity to extreme temperatures. In 1997, we enrolled a prospective cohort of 719 Indigenous people in a remote Aboriginal community in Australia’s Northern Territory (see the eAppendix for Materials and Methods, and Results, https://links.lww.com/EDE/A669). Hospitalization discharge diagnoses (International Classification of Diseases, Tenth Revision: A00–R99) were recorded for every participant between 1997 and 2004. Data on daily minimum temperatures were linked to hospitalization data using dates of hospitalization. We used a time-stratified case-crossover analysis to explore associations of temperature with risk of hospitalization.3 Hotter minimum temperatures were associated with an increased risk of hospitalization for all participants, particularly for overweight people and men. Colder minimum temperatures were associated with increased risk of hospitalization for women. Both cold and hot temperatures were associated with an increased risk of hospitalization in older people (Figure).FIGURE: Nonlinear associations between temperature and hospitalization using a case-crossover model. Temperature has a lag of 0–21 days and 4 degrees of freedom natural cubic spline. The thick lines are log odds ratios and the thin lines are 95% confidence intervals. The dotted horizontal line represents no change in risk.We used a case-only analysis4 to examine susceptibility of particular groups to cold or hot temperatures (eAppendix, Figure 2 and Table 4, https://links.lww.com/EDE/A669). Overweight people were more likely than normal weight people to be hospitalized during extremely hot days but not during cold days. Similarly, men were at a greater risk of hospitalization during hot days than women. Older people had a greater risk of hospitalization during both cold and hot days (eAppendix, Figure 2 and Table 4, https://links.lww.com/EDE/A669). Understanding who is susceptible to extreme temperatures is important in minimizing the public health impact of extreme weather. One notable result is the susceptibility of overweight people to hot but not cold temperatures. The prevalence of overweight and obesity among adult Indigenous Australians has been steadily increasing (from 51% in 1995 to 60% in 2005)5 as it has in many other populations.6 Another important finding is the much greater risk of hospitalization on hot days for men than for women. This might be caused by biological differences (eg, differences in body fat) or behavioral differences (eg, differences in clothing).7 Older people were clearly more sensitive to both cold and hot temperatures than younger people. This presumably reflects the declining physiological function of the elderly, whose thermal regulation system weakens with age.8 Overall, hot temperatures substantially increased the risk of hospitalization for Indigenous Australians. The vulnerability of this population—and specific subgroups of the population—should be taken into account in public policies dealing with the health of indigenous people. ACKNOWLEDGMENTS We thank the Aboriginal people who participated in this study. We thank David Ung (The Northern Territory Department of Health and Community Services) who helped obtain the hospitalization data and the weather underground website for making weather data publically available. Yuming Guo School of Medicine University of Queensland Herston, Queensland, Australia [email protected] Zhiqiang Wang School of Medicine University of Queensland Herston, Queensland, Australia Shanshan Li School of Population Health University of Queensland Herston, Queensland, Australia Shilu Tong Adrian G. Barnett School of Public Health and Social Work Institute of Health and Biomedical Innovation Queensland University of Technology Kelvin Grove, Queensland, Australia

Medication adherence in schizophrenia: The role of insight, therapeutic alliance and perceived trauma associated with psychiatric care

Background Medication adherence is essential in the management of schizophrenia. Yet poor treatment uptake has negative consequences on patients and their primary caregivers. Objective To examine the association among beliefs about psychotropic medications, side effects and adherence from a patient-caregiver dyad perspective. Setting This study was conducted in a public psychiatric hospital setting in Accra, Ghana. Methods A cross-sectional study was conducted among 121 patient-caregiver dyads using an interviewer-administered data collection approach.Main outcome measure Beliefs about medicines, side-effects and medication adherence. Results The patient and caregiver-reported level of medication adherence was 28.1 %. Using the Kappa index, the level of agreement between the responses of patients and their caregivers ranged from slight to moderate. Both patients and caregivers rated necessity higher than concern (patients: 1.67 ± 0.84, caregiver: 1.79 ± 0.96). Significant positive relations between specific-necessity, necessity-concerns differential and medication adherence were recorded while specific-concern, general harm and side-effects correlated negatively with medication adherence from the dyad. The odds of adhering to medications increased by 58 and 64 % for each unit increase in specific-necessity and general overuse scores respectively. However, a unit increase in specific-concern score and high side-effects scores were associated with lower odds of adherence. Conclusions This study highlights the need for patient-caregiver collaborations in decision-making relating to medication adherence in schizophrenia. Thus, in clinical practice, there is the need to recognize that caregivers are essential partners, and patient-caregiver views about psychotropic medications are critical in enhancing adherence for positive mental health outcomes.