Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies
Identifieur interne : 000356 ( Pmc/Curation ); précédent : 000355; suivant : 000357Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies
Auteurs : Peter M. Haddad [Royaume-Uni] ; Cecilia Brain [Suède] ; Jan Scott [Royaume-Uni]Source :
- Patient Related Outcome Measures [ 1179-271X ] ; 2014.
Abstract
Nonadherence with medication occurs in all chronic medical disorders. It is a particular challenge in schizophrenia due to the illness’s association with social isolation, stigma, and comorbid substance misuse, plus the effect of symptom domains on adherence, including positive and negative symptoms, lack of insight, depression, and cognitive impairment. Nonadherence lies on a spectrum, is often covert, and is underestimated by clinicians, but affects more than one third of patients with schizophrenia per annum. It increases the risk of relapse, rehospitalization, and self-harm, increases inpatient costs, and lowers quality of life. It results from multiple patient, clinician, illness, medication, and service factors, but a useful distinction is between intentional and unintentional nonadherence. There is no gold standard approach to the measurement of adherence as all methods have pros and cons. Interventions to improve adherence include psychoeducation and other psychosocial interventions, antipsychotic long-acting injections, electronic reminders, service-based interventions, and financial incentives. These overlap, all have some evidence of effectiveness, and the intervention adopted should be tailored to the individual. Psychosocial interventions that utilize combined approaches seem more effective than unidimensional approaches. There is increasing interest in electronic reminders and monitoring systems to enhance adherence, eg, Short Message Service text messaging and real-time medication monitoring linked to smart pill containers or an electronic ingestible event marker. Financial incentives to enhance antipsychotic adherence raise ethical issues, and their place in practice remains unclear. Simple pragmatic strategies to improve medication adherence include shared decision-making, regular assessment of adherence, simplification of the medication regimen, ensuring that treatment is effective and that side effects are managed, and promoting a positive therapeutic alliance and good communication between the clinician and patient. These elements remain essential for all patients, not least for the small minority where vulnerability and risk issue dictate that compulsory treatment is necessary to ensure adherence.
Url:
DOI: 10.2147/PROM.S42735
PubMed: 25061342
PubMed Central: 4085309
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<front><div type="abstract" xml:lang="en"><p>Nonadherence with medication occurs in all chronic medical disorders. It is a particular challenge in schizophrenia due to the illness’s association with social isolation, stigma, and comorbid substance misuse, plus the effect of symptom domains on adherence, including positive and negative symptoms, lack of insight, depression, and cognitive impairment. Nonadherence lies on a spectrum, is often covert, and is underestimated by clinicians, but affects more than one third of patients with schizophrenia per annum. It increases the risk of relapse, rehospitalization, and self-harm, increases inpatient costs, and lowers quality of life. It results from multiple patient, clinician, illness, medication, and service factors, but a useful distinction is between intentional and unintentional nonadherence. There is no gold standard approach to the measurement of adherence as all methods have pros and cons. Interventions to improve adherence include psychoeducation and other psychosocial interventions, antipsychotic long-acting injections, electronic reminders, service-based interventions, and financial incentives. These overlap, all have some evidence of effectiveness, and the intervention adopted should be tailored to the individual. Psychosocial interventions that utilize combined approaches seem more effective than unidimensional approaches. There is increasing interest in electronic reminders and monitoring systems to enhance adherence, eg, Short Message Service text messaging and real-time medication monitoring linked to smart pill containers or an electronic ingestible event marker. Financial incentives to enhance antipsychotic adherence raise ethical issues, and their place in practice remains unclear. Simple pragmatic strategies to improve medication adherence include shared decision-making, regular assessment of adherence, simplification of the medication regimen, ensuring that treatment is effective and that side effects are managed, and promoting a positive therapeutic alliance and good communication between the clinician and patient. These elements remain essential for all patients, not least for the small minority where vulnerability and risk issue dictate that compulsory treatment is necessary to ensure adherence.</p>
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<pmc article-type="review-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Patient Relat Outcome Meas</journal-id>
<journal-id journal-id-type="iso-abbrev">Patient Relat Outcome Meas</journal-id>
<journal-id journal-id-type="publisher-id">Patient Related Outcome Measures</journal-id>
<journal-title-group><journal-title>Patient Related Outcome Measures</journal-title>
</journal-title-group>
<issn pub-type="epub">1179-271X</issn>
<publisher><publisher-name>Dove Medical Press</publisher-name>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">25061342</article-id>
<article-id pub-id-type="pmc">4085309</article-id>
<article-id pub-id-type="doi">10.2147/PROM.S42735</article-id>
<article-id pub-id-type="publisher-id">prom-5-043</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Review</subject>
</subj-group>
</article-categories>
<title-group><article-title>Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies</article-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Haddad</surname>
<given-names>Peter M</given-names>
</name>
<xref ref-type="aff" rid="af1-prom-5-043">1</xref>
<xref ref-type="aff" rid="af2-prom-5-043">2</xref>
<xref ref-type="corresp" rid="c1-prom-5-043"></xref>
</contrib>
<contrib contrib-type="author"><name><surname>Brain</surname>
<given-names>Cecilia</given-names>
</name>
<xref ref-type="aff" rid="af3-prom-5-043">3</xref>
<xref ref-type="aff" rid="af4-prom-5-043">4</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Scott</surname>
<given-names>Jan</given-names>
</name>
<xref ref-type="aff" rid="af5-prom-5-043">5</xref>
<xref ref-type="aff" rid="af6-prom-5-043">6</xref>
</contrib>
</contrib-group>
<aff id="af1-prom-5-043"><label>1</label>
Neuroscience and Psychiatry Unit, University of Manchester, Manchester, UK</aff>
<aff id="af2-prom-5-043"><label>2</label>
Greater Manchester West Mental Health NHS Foundation Trust, Salford, UK</aff>
<aff id="af3-prom-5-043"><label>3</label>
Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Sahlgrenska Academy, University of Gothenburg, Sweden</aff>
<aff id="af4-prom-5-043"><label>4</label>
Nå Ut-teamet, Psychosis Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden</aff>
<aff id="af5-prom-5-043"><label>5</label>
Academic Psychiatry, Institute of Neuroscience, Newcastle University, London, UK</aff>
<aff id="af6-prom-5-043"><label>6</label>
Centre for Affective Disorders, Institute of Psychiatry, London, UK</aff>
<author-notes><corresp id="c1-prom-5-043">Correspondence: Peter M Haddad, Greater Manchester West Mental Health NHS Foundation Trust, Cromwell House, Eccles, Salford, M30 0GT, UK, Tel +44 161 787 6007, Email <email>peter.haddad@gmw.nhs.uk</email>
</corresp>
</author-notes>
<pub-date pub-type="collection"><year>2014</year>
</pub-date>
<pub-date pub-type="epub"><day>23</day>
<month>6</month>
<year>2014</year>
</pub-date>
<volume>5</volume>
<fpage>43</fpage>
<lpage>62</lpage>
<permissions><copyright-statement>© 2014 Haddad et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License</copyright-statement>
<copyright-year>2014</copyright-year>
<license><license-p>The full terms of the License are available at <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/">http://creativecommons.org/licenses/by-nc/3.0/</ext-link>
. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.</license-p>
</license>
</permissions>
<abstract><p>Nonadherence with medication occurs in all chronic medical disorders. It is a particular challenge in schizophrenia due to the illness’s association with social isolation, stigma, and comorbid substance misuse, plus the effect of symptom domains on adherence, including positive and negative symptoms, lack of insight, depression, and cognitive impairment. Nonadherence lies on a spectrum, is often covert, and is underestimated by clinicians, but affects more than one third of patients with schizophrenia per annum. It increases the risk of relapse, rehospitalization, and self-harm, increases inpatient costs, and lowers quality of life. It results from multiple patient, clinician, illness, medication, and service factors, but a useful distinction is between intentional and unintentional nonadherence. There is no gold standard approach to the measurement of adherence as all methods have pros and cons. Interventions to improve adherence include psychoeducation and other psychosocial interventions, antipsychotic long-acting injections, electronic reminders, service-based interventions, and financial incentives. These overlap, all have some evidence of effectiveness, and the intervention adopted should be tailored to the individual. Psychosocial interventions that utilize combined approaches seem more effective than unidimensional approaches. There is increasing interest in electronic reminders and monitoring systems to enhance adherence, eg, Short Message Service text messaging and real-time medication monitoring linked to smart pill containers or an electronic ingestible event marker. Financial incentives to enhance antipsychotic adherence raise ethical issues, and their place in practice remains unclear. Simple pragmatic strategies to improve medication adherence include shared decision-making, regular assessment of adherence, simplification of the medication regimen, ensuring that treatment is effective and that side effects are managed, and promoting a positive therapeutic alliance and good communication between the clinician and patient. These elements remain essential for all patients, not least for the small minority where vulnerability and risk issue dictate that compulsory treatment is necessary to ensure adherence.</p>
</abstract>
<kwd-group><title>Keywords</title>
<kwd>adherence</kwd>
<kwd>nonadherence</kwd>
<kwd>antipsychotics</kwd>
<kwd>schizophrenia</kwd>
<kwd>long-acting injections</kwd>
<kwd>relapse</kwd>
<kwd>risk factors</kwd>
</kwd-group>
</article-meta>
</front>
<floats-group><fig id="f1-prom-5-043" position="float"><label>Figure 1</label>
<caption><p>Efficacy of maintenance antipsychotic medication versus placebo in schizophrenia (65 trials, n=6,493).</p>
<p><bold>Notes:</bold>
Data are n/N (%) unless otherwise stated. The random effects model by DerSimonian and Laird<xref rid="b144-prom-5-043" ref-type="bibr">144</xref>
was used throughout, with weights calculated by the Mantel–Haenszel method. *Weighted by sample size of individual trials. <sup>†</sup>
Because of space limitations, we did not use the display suggested by Altman.<xref rid="b145-prom-5-043" ref-type="bibr">145</xref>
Reprinted from The Lancet, 379, Leucht S, Tardy M, Komossa K, et al, Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis, 2063–2071, Copyright © 2012, with permission from Elsevier.<xref rid="b11-prom-5-043" ref-type="bibr">11</xref>
</p>
<p><bold>Abbreviations:</bold>
AE, adverse event; MD, movement disorder; n, number of participants with an event; N, number of studies; CI, confidence interval; NNTB/NNTH, number needed to treat to benefit/harm; H, harm; B, benefit.</p>
</caption>
<graphic xlink:href="prom-5-043Fig1"></graphic>
</fig>
<fig id="f2-prom-5-043" position="float"><label>Figure 2</label>
<caption><p>Consequences of nonadherence to antipsychotic medication.</p>
<p><bold>Note:</bold>
This material was originally published in Antipsychotic long-acting injections (edited by P Haddad, T Lambert and J Lauriello) and has been reproduced by permission of Oxford University Press. <ext-link ext-link-type="uri" xlink:href="http://ukcatalogue.oup.com/product/9780199586042.do">http://ukcatalogue.oup.com/product/9780199586042.do</ext-link>
. For permission to reuse this material, please visit <ext-link ext-link-type="uri" xlink:href="http://www.oup.co.uk/academic/rights/permissions">http://www.oup.co.uk/academic/rights/permissions</ext-link>
.<xref rid="b146-prom-5-043" ref-type="bibr">146</xref>
</p>
<p><bold>Abbreviation:</bold>
QoL, Quality of life.</p>
</caption>
<graphic xlink:href="prom-5-043Fig2"></graphic>
</fig>
<fig id="f3-prom-5-043" position="float"><label>Figure 3</label>
<caption><p>Association between antipsychotic nonadherence and outcome in a 3-year prospective observational US study.</p>
<p><bold>Notes:</bold>
Adherence based on patient-reported adherence and medication possession ratio (% days with prescription for any antipsychotic). Data adapted from Ascher-Svanum H, Faries DE, Zhu B, Ernst FR, Swartz MS, Swanson JW. Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care. <italic>J Clin Psychiatry</italic>
. 2006;67(3):453–460.<xref rid="b29-prom-5-043" ref-type="bibr">29</xref>
Copyright © 2006, Physician’s Postgraduate Press, Inc.</p>
<p><bold>Abbreviation:</bold>
Psych, psychiatric.</p>
</caption>
<graphic xlink:href="prom-5-043Fig3"></graphic>
</fig>
<fig id="f4-prom-5-043" position="float"><label>Figure 4</label>
<caption><p>Factors associated with nonadherence.</p>
</caption>
<graphic xlink:href="prom-5-043Fig4"></graphic>
</fig>
<table-wrap id="t1-prom-5-043" position="float"><label>Table 1</label>
<caption><p>Methods of assessing medication adherence</p>
</caption>
<table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" rowspan="1" colspan="1">Objective adherence measurement</th>
<th align="left" valign="top" rowspan="1" colspan="1">Subjective adherence measurement</th>
</tr>
</thead>
<tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">Medication container with electronic monitoring, eg, MEMS Pill count</td>
<td align="left" valign="top" rowspan="1" colspan="1">Clinician’s view on adherence (often based on therapeutic response and side effects)</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">Biological markers</td>
<td align="left" valign="top" rowspan="1" colspan="1">Patient or key other report<xref ref-type="table-fn" rid="tfn1-prom-5-043">*</xref>
</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">Observed intake</td>
<td align="left" valign="top" rowspan="1" colspan="1">Patient diary of medication intake</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">Medication possession ratio</td>
<td align="left" valign="top" rowspan="1" colspan="1">Questionnaires, eg, DAI, MARS</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">Medication plasma level</td>
<td align="left" valign="top" rowspan="1" colspan="1"></td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">Electronic ingestible event marker</td>
<td align="left" valign="top" rowspan="1" colspan="1"></td>
</tr>
</tbody>
</table>
<table-wrap-foot><fn><p><bold>Note:</bold>
</p>
</fn>
<fn id="tfn1-prom-5-043"><label>*</label>
<p>Patient, case manager, other health care professional, next-of-kin, or carer are asked to estimate the adherence of the patient.</p>
</fn>
<fn id="tfn2-prom-5-043"><p><bold>Abbreviations:</bold>
MEMS, Medication Event Monitoring System; DAI, Drug Attitude Inventory; MARS, Medication Adherence Rating Scale.</p>
</fn>
</table-wrap-foot>
</table-wrap>
</floats-group>
</pmc>
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