Promoting Treatment Adherence in Patients with BD

DetectionToo often, psychiatric patients do not adhere to their treatment plans, whether they be pharmacological or psychotherapeutic, and, specifically, between 21 and 50 percent of those with bipolar disorder (BD) do not adhere.[1] BD is a lifelong illness, and a prevalent one at that, with effects that can often be debilitating.[2] Unfortunately, nonadherence leads to a worsening prognosis and even further burden of illness. However, choosing the best treatment plan to fit a BD patient’s perspectives and goals can be difficult.2 In their article, “Promoting Treatment Adherence in Patients with Bipolar Disorder,” Foster and colleagues review methods of adherence, factors that affect them, and both pharmacological and psychosocial interventions that help improve them.

Adhering to treatment plans ultimately decreases the suicide rate among patients who suffer from BD. For example, over a period of 40 years Angst and colleagues studied the suicide rate of 406 patients who suffered from either BD or unipolar depression.[3] Eleven percent committed suicide, and patients who were left untreated had a higher mortality rate.9

Foster and colleagues report several tools used to measure patient adherence to treatment plans; however, as most are not effective, they suggest using a combination to obtain the most accurate measure.[4] One method is attitudinal scales, which are able to depict the patient’s subjective feelings to having to take medicine, how they perceive the therapeutic doctor-patient agreement, and the stigmas faced.2 However, attitudinal scales often over-estimate adherence levels. Physicians may also use pill counts to measure adherence; however, a significant drawback, patients are able to manipulate the medication.2 Electronic medication monitors are able to record the times specific doses of medicine are administered, but do not completely guarantee the medication was ingested and can be an expensive method.2 Another method, measuring drug levels in urine or blood, can measure adherence but is also expensive.2

Although patients may share a diagnosis, the factors that lead them to stray from their treatment plans vary greatly with each individual. For example, a patient’s age, gender, culture, socioeconomic status, self-image, symptom severity, and opinion of mental illness can all influence a patient to adhere to treatment or not.[5] An obvious reason for nonadherence is whether or not a medicine is decreasing a patient’s debilitating symptoms.2 If the medicine does not seem to be helping, nonadherence is high. Also, as patients often feel more affected by their depressive symptoms than by their manic symptoms, a treatment that reduces the depressive effects will more likely promote adherence.[6] Another factor for medicine adherence is tolerability. Many patients report that side-effects of weight-gain and cognitive impairment are the more important factors in their decision to adhere.[7] Deficits in memory and cognitive functioning will more likely lead to nonadherence. Finally, a positive partnership with a clinician is key to treatment adherence.[8] Patients who understand the role medicine plays in their illness are more likely to adhere.[9]

When a medicine regiment is more complex, Foster and colleagues state that adherence tends to decrease.2 Therefore, both patients and clinicians may prefer to treat with a once-daily dosage. As an added benefit, once-daily dosing drugs often provide a consistent amount of medicine throughout the day and have fewer side-effects than medicine needing to be taken multiple times per day.2 Foster and colleagues describe divalproex extended-release as a well-tolerated treatment for BD.2 Fifty-two percent of patients who switched to the medicine showed improvement in mood, and 81 percent did not experience side-effects.[10] Also, similar to divalproex, carbamazepine is also an effective treatment, especially for acute mania.2 Extended-release antidepressants, although controversial in the treatment of BD, are used in 44 percent of cases.5 It is thought that these medicines can optimize drug delivery and minimize side effects.1

Foster and colleagues also state that many atypical antipsychotics are FDA-approved for the treatment of mania, acute bipolar depression, and maintenance.2 Long-acting injectable formulations (LAIs) are often used for maintenance, especially if nonadherence is an issue for the patient. Risperidone[11] and asenapine are commonly used LAIs that were found to work well with patients with bipolar disorder I.[12]

The following psychosocial treatments are used with BD patients: psychoeducation, cognitive-behavioral therapy, family-focused interventions, and interpersonal and social rhythm therapy.[13] According to Foster and colleagues, psychoeducation alone or used in combination with another psychosocial treatment can decrease a patient’s risk of relapse and increase adherence to treatment.[14] For example, Miklowitz and colleagues reported that of 293 BD patients who randomly received intensive psychotherapy—either cognitive-behavioral therapy, interpersonal and social rhythm therapy, or psychoeducational therapy—more tended to improve symptoms after one year than those who did not.[15]

Overall, Foster and colleagues stress the importance of taking into consideration each patient’s unique perspectives and goals when planning a treatment regiment, in order to maximize adherence, and ultimately, symptom improvement. This includes tailoring the medicine and the psychotherapy to fit the patient’s lifestyle and unique personality, as a combination of both pharmacological and psychotherapeutic therapies works most efficiently in patients with bipolar disorder.

[1] Buckley PF, Foster AE, Patel NC, et at. Adherence to mental health treatment. New York., NY: Oxford University Press; 2009:1-10, 53-69.

[2] Foster, A.; Sheehan, L.; Johns, L. (2011). Promoting Treatment Adherence in Patients with Bipolar Disorder. Current Psychiatry 10(7): 45-52.

[3] Angst J, Angst F, Gerber-Werder R, et al. Suicide in 406 mood disorder patients with and without long-term medication a 40 to 44 years’ follow-up. Arch Suicide Res. 20059:279-300.

[4] Velligan D, Sajatovic M, Valenstein M, et al. Methodological challenges in psychiatric treatment adherence research. Clin Schizophr Relat Psychoses. 2010;4(1):74-91.

[5] Berk L, Hallam KT, Colom F, et al. Enhancing medication adherence in patients with bipolar disorder. Hum PsychopharmacoL 201025(1):1-16.

[6] Sajatovic M, Jenkins JH, Cassidy KA, et al. Medication treatment perceptions, concerns and expectations among depressed individuals with type I bipolar disorder. J Affect Disord. 2009;115(3):360-366.

[7] Johnson FR, Ozdemir S, Manjunath R, et aL Factors that affect adherence to bipolar disorder treatments: a stated-preference approach. Med Care. 2007;45(6):545-552.

[8] Gaudiano BA, Miller 1W Patients’ expectancies, the alliance in pharmacotherapy, and treatment outcomes in bipolar disorder. J Consult Clin Psychol. 2006;74(4):671-676.

[9] Copeland LA, Zeber JE, Salloum IM, et al. Treatment adherence and illness insight in veterans with bipolar disorder. J Nery Ment Dis. 2008;196(1):16-21.

[10] Minirth FB, Neal V. Assessment of patient preference and side effects in patients switched from divalproex sodium delayed release to divalproex sodium extended release. J Clin Psychopharmacol. 20052599-101.

[11] Han C, Lee MS, Pae CU, et al. Usefulness of long-acting injectable risperidone during 12-month maintenance therapy of bipolar disorder. Prog Neuropsychopharmacol Biol Psychiatry 2007;31:1219-1223.

[12] McIntyre RS, Cohen M, Zhao J, et al. Asenapine for long term treatment of bipolar disorder: a double blind 40-week extension study. J Affect Disord. 2010;126:358-365.

[13] Szentagotai A, David D. The efficacy of cognitive-behavioral therapy in bipolar clisorder a quantitative meta-analysis. J Clin Psychiatry. 2010;71(1):66-72.

[14] Velligan DI, Weiden PJ, Sajatovic M, et al. Strategies for addressing adherence problems in patients with serious and persistent mental illness: recommendations from expert consensus guidelines. J Psychiatr Prato. 2010;16(5):306-324.

[15] Mildowitz DJ, Otto MW, Frank E, et al. Psychosocial treatments for bipolar depression: A 1-year randomized trial from the Systematic Treatment Enhancement Program. Arch Gen Psychiatry. 2007;64:419426.

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