Psychoeducational Approaches to Medication Adherence in Patients with Bipolar Disorder

Martha Sajatovic1, Peijun Chen2, Philipp Dines3, Edwin R. Shirley3
1Departments of Psychiatry and Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, USA
2Department of Psychiatry, Case Western Reserve University School of Medicine, Louis Stokes VAMC, Cleveland, USA
3Department of Psychiatry, Case Western Reserve University, School of Medicine, Cleveland, USA

Tóm tắt

There is growing consensus that a major obstacle to good outcomes among individuals with bipolar disorder (BPD) is premature discontinuation of medications. This review summarizes the current literature on prevalence and consequences of non-adherence in BPD populations, measurement of adherence, risk factors for non-adherence, and general and psychoeducational interventions to enhance treatment adherence among bipolar populations, and suggests future directions in psychoeducational approaches with respect to treatment adherence. Risks associated with discontinuation of medication among individuals with BPD are well documented and include manic and depressive relapses, re-hospitalization, and more lengthy hospital stays. A relatively limited but growing literature suggests that it is possible to enhance treatment adherence among patients with BPD. The most positive evidence for the improvement of medication adherence among patients with BPD comes from specific psychosocial interventions used in conjunction with pharmacotherapies. It has been suggested that improved treatment adherence is at least a partial component of the observed positive outcomes of psychoeducational approaches among bipolar populations. Many individuals with BPD remain relatively uninformed regarding their illness, creating potential barriers to optimal treatment adherence, and limiting self-management skills. Psychoeducation is based on the premise that individuals have a fundamental right to have information regarding their illness, and individuals who are informed are more likely to take a more active role in managing their illness, which results in better health outcomes. Psychoeducation strategies for BPD that have contributed to positive outcomes have ranged from simple one-site, education-only interventions that improve lithium adherence and attitudes about medications to a more complex, multi-site, collaborative care system intervention that yielded shorter durations of affective episodes for patients, improved functioning and quality of life, and treatment satisfaction. Although psychological therapies that emphasize psychoeducation generally support benefits in achieving and maintaining remission from bipolar symptoms, the effects of these interventions on treatment adherence are not consistent and the way in which psychoeducation improves outcomes is not entirely clear. There is an urgent need for greater understanding of interventions that can be implemented in real-world settings that address patient, provider/system, and environmental/social factors that are critical to treatment adherence.

Từ khóa


Tài liệu tham khảo

Murray CJ, Lopez AD. Global mortality, disability and the contribution of risk factors: Global Burden of Disease study. Lancet 1997; 349: 1436–42

Begley CE, Annegers JF, Swann AC, et al. The lifetime cost of bipolar disorder in the US: an estimate for new cases in 1998. Pharmacoeconomics 2001; 19: 483–95

Colom F, Vieta E, Martinez-Aran A, et al. Clinical factors associated with treatment noncompliance in euthymic bipolar patients. J Clin Psychiatry 2000; 61(8): 549–55

American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry 2002; 159 Suppl. 4: 1–50

Keck PE Jr. Defining and improving response to treatment in patients with bipolar disorder. J Clin Psychiatry 2004; 65 (15 Suppl.): 25–9

Goodwin GM, Young AH. The British Association for Psychopharmacology guidelines for treatment of bipolar disorder: a summary. J Psychopharmacol 2003; 17 (4 Suppl.): 3–6

Yatham LN, Kennedy SH, O’Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disord 2005; (3 Suppl.): 5-69

Colom F, Vieta E, Tacci MJ, et al. Identifying and improving non-adherence in bipolar disorder. Bipolar Disord 2005; 7 (5 Suppl.): 24–31

Lingam R, Scott J. Treatment non-adherence in affective disorder. Acta Psychiatr Scand 2002; 105(3): 164–72

Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353: 487–97

Lieberman JA, Stroup TS, McEvoy JP, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 2005; 353(12): 1209–23

Jamison KR, Gerner RH, Goodwin FK. Patient and physician attitudes towards lithium. Arch Gen Psychiatry 1979; 36: 866–9

Scott J. Using health belief models to understand the efficacy-effectiveness gap for mood stabilizer treatments. Neuropsychobiology 2002; 46 (1 Suppl.): 13–5

Perlick DA, Rosenheck RA, Kacynski R, et al. Medication non-adherence in bipolar disorder: a patient-centered review of research findings. Clin App Bipolar Disord 2004; 3: 56–4

Schou M. The combat on non-compliance during prophylactic lithium treatment. Acta Psychiatr Scan 1997; 95: 361–3

Franks MA, Macritchie KAN, Young AH. The consequences of suddenly stopping psychotropic medication in bipolar disorder. Clin app bipolar disord 2005; 4: 11–7

Mander AJ, Loudon JB. Rapid recurrence of mania following abrupt discontinuation of lithium. Lancet 1988; II: 15–7

Mander AJ. Use of lithium and early relapse in manic-depressive illness. Acta Psychiatr Scand 1988; 78: 198–200

Strakowski SM, Keck PE, McElroy SL, et al. Twelve-month outcome after a first hospitalization for affective psychosis. Arch Gen Psychiatry 1998; 55: 49–55

Tohen M, Greil W, Calabrese JR, et al. Olanzapine versus lithium in the maintenance treatment of bipolar disorder: a 12-month randomized, double blind, controlled clinical trial. Am J Psychiatry 2005; 162: 1281–90

Svarstad BL, Shirman TI, Seeney JK. Using drug claims data to assess the relationship of medication adherence with hospitalization and costs. Psychiatr Serv 2001; 52: 805–11

Muller-Oerlinghausen B, Wolf T, Ahrens B, et al. Mortality of patients who dropped out from regular lithium prophylaxis: a collaborative study by the International Group for the Study of Lithium-treated patients (IGSLI). Acta Psychiatr Scan 1996; 94: 344–7

Muller-Oerlinghausen B. Arguments for the specificity of the antisuicidal effect of lithium. Eur Arch Psychiatry Clin Neurosci 2001; 251 (2 Suppl.): 1172–5

Durrenberger S, Rogers T, Walker R, et al. Economic grand rounds: the high costs of care for four patients with mania who were not compliant with treatment. Psychiatr Serv 1999; 50: 1539–42

Sajatovic M, Davies M, Hrouda DR. Enhancement of treatment adherence among patients with bipolar disorder. Psychiatr Serv 2004; 55: 264–9

Bender BG. Screening patients for nonadherence. Female Patient 2005; 30: 34–7

Miklowitz DJ, Simoneau TL, George EL, et al. Family-focused treatment of bipolar disorder: 1-year effects of a psychoeducational program in conjunction with pharmacotherapy. Biol Psychiatry 2000; 48: 582–92

Cochran SD. Preventing medical noncompliance in outpatient treatment of bipolar disorders. J Consult Clin Psychol 1984; 52: 873–8

DiMatteo MR. Variation in patients’ adherence to medical recommendations. Med Care 2004; 42(3): 200–9

National Heart, Lung, and Blood Institute. Expert Panel 2. Clinical practice guidelines for the diagnosis and management of asthma, NIH Pub No 97-4051. Bethesda (MD): National Institutes of Health, 1997 Jul

Barr RG, Somers SC, Speizer FE, et al. National Asthma Education and Prevention Program (NAEPP). Patient factors and medication guideline adherence among older women with asthma. Arch Intern Med 2002; 162(15): 1761–8

Haywood TW, Kravitz HM, Grossman LS, et al. Predicting the “revolving door” phenomenon among patients with schizophrenic, schizoaffective, and affective disorders. Am J Psychiatry 1995; 152(6): 856–61

Olfson M, Marcus SC, Wilk J, et al. Awareness of illness and nonadherence to antipsychotic medications among persons with schizophrenia. Psychiatr Serv 2006; 57: 205–11

Compton MR, Rudisch BE, Weiss PS, et al. Predictors of psychiatrist-reported treatment-compliance problems among patients in routine US psychiatry care. Psychiatric Res 2005; 137: 29–36

Leo RJ, Jassal K, Bakhai YD. Nonadherence with psychopharmacologic treatment among psychiatric patients. Prim Psychiatry 2005; 12(6): 33–9

Leucht S, Heres S. Epidemiology, clinical consequences, and psychosocial treatment of nonadherence in schizophrenia. J Clin Psychiatry 2006; 67 Suppl. 5: 3–8

Hunt GE, Bergen J, Bashir M. Medication compliance and comorbid substance abuse in schizophrenia: impact on community survival 4 years after relapse. Schizophr Res 2002; 54: 253–64

Byerly M, Fisher R, Rush AJ, et al. A comparison of physician versus electronic monitoring of antipsychotic adherence in schizophrenia [poster]. 41st Annual Meeting of the American College of Neuropsychopharmacology; 2002 Dec 8–12; San Juan

Sajatovic M, Bauer MS, Kilbourne AM, et al. Self-reported medication treatment adherence among veterans with bipolar disorder. Psychiatr Serv 2006; 57(1): 56–62

Keck PE, McElroy SL, Strkowski SM, et al. Factors associated with pharmacologic noncompliance in patients with mania. J Clin Psychiatry 1996; 57(7): 292–7

Fleck DE, Keck PE, Corey KB, et al. Factors associated with medication adherence in African American and White patients with bipolar disorder. J Clin Psychiatry 2005; 66: 646–52

Sajatovic M, Valenstein M, Blow FC, et al. Treatment adherence with antipsychotic medications in bipolar disorder. Bipolar Disord 2006; 8(3): 232–41

Martinez-Aran A, Vieta E, Reinares M, et al. Cognitive function across manic or hypomanic, depressed, and euthymic states in bipolar disorder. Am J Psychiatry 2004; 161: 262–70

Scott J, Pope M. Non-adherence with mood stabilizers: prevalence and predictors. J Clin Psychiatry 2002; 63: 384–90

Sajatovic M, Jenkins JH, Safavi R, et al. Personal and societal construction of illness among individuals with rapid cycling BPD: a life-trajectory perspective. Am J Geriatr Psychiatry. In press

Colom F, Vieta E. Treatment adherence in bipolar patients. Clin App Bipolar Disord 2002; 1: 49–56

Pope M, Scott J. Do clinicians understand why individuals stop taking lithium? J Affect Disord 2003; (74): 287–91

Lincoln A, Paasche-Orlow MK, Cheng DM, et al. Impact of health literacy on depressive symptoms and mental health: quality of life among adults with addiction. J Gen Intern Med 2006; 21(8): 818–22

Schaffer A, Cairney J, Cheung AH, et al. Use of treatment services and pharmacotherapy for bipolar disorder in a general population-based mental health survey. J Clin Psychiatry 2006; 67(3): 386–93

Gianfrancesco FD, Rajagopalan K, Sajatovic M, et al. Treatment adherence among patients with bipolar or manic disorder taking atypical and typical antipsychotics. J Clin Psychiatry 2006; 67(2): 222–32

Young JL, Spitz RT, Hillbrand M, et al. Medication adherence failure in schizophrenia: a forensic review of rates, reasons, treatment and prospects. J Am Acad Psychiatry Law 1999; 27(30): 426–44

Kleindienst N, Greil W. Are illness concepts a powerful predictor of adherence to prophylactic treatment in bipolar disorder? J Clin Psychiatry 2004 Jul; 65(7): 966–74

Lee S, Wing YK, Wong KC. Knowledge and compliance towards lithium therapy among Chinese psychiatric patients in Hong Kong. Aust N Z J Psychiatry 1992; 26(3): 444–9

Clarkin JF, Carpenter D, Hull J, et al. Effects of psychoeducational intervention for married patients with bipolar disorder and their spouses. Psychiatr Serv 1998; 49(4): 531–3

Harvey NS, Peet M. Lithium maintenance: effects of personality and attitude on healthy information acquisition and compliance. Br J Psychiatry 1991; 158: 200–4

Colom F, Vieta E, Martinez-Aran A, et al. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry 2003; 60(4): 402–7

Miklowitz DJ, Geogre EL, Richards JA, et al. A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Arch Gen Psychiatry 2003; 60: 904–12

Lam DH, Watkins ER, Hayward P, et al. A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year. Arch Gen Psychiatry 2003 Feb; 60(2): 145–52

Berk M, Berk L, Castle D. A collaborative approach to the treatment alliance in bipolar disorder. Bipolar Disord 2004; 6(6): 504–18

Watkins CE. Psychoeducational training in counseling psychology programs: some thoughts on a training curriculum. Couns Psychol 1985; 13(2): 295–302

Goldman CR. Toward a definition of psychoeducation. Hosp Community Psychiatry 1988; 39(6): 666–8

Frank E, Kupfer DJ, Thase ME, et al. Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Arch Gen Psychiatry 2005; 62: 996–1004

Perry A, Tarrier N, Morriss R, et al. Randomized controlled trial of efficacy of teaching patients with bipolar disorder. BMJ 1999; 318: 149–53

Colom F, Vieta E, Sanchez-Moreno J, et al. Stabilizing the stabilizer: group psychoeducation enhances the stability of serum lithium levels. Bipolar Disord 2005; 7 Suppl. 5: 32–6

Miklowitz DJ, Otto MW. New psychosocial interventions for bipolar disorder: a review of literature and introduction of the systematic treatment enhancement program. J Cognitive Psychotherapy 2006; 20(2): 215–30

Scott J, Colom F, Vieta E. A meta-analysis of relapse rates with adjunctive psychological therapies compared to usual psychiatric treatment for bipolar disorder. Int J Neuropsychopharmacol 2007 Feb; 10(1): 123–9

Morselli PL, Elgie R. GAMIAN-Europe. GAMIAN-Europe/BEAM survey I: global analysis of a patient questionnaire circulated to 3450 members of the 12 European advocacy groups operating in the field of mood disorders. Bipolar Disord 2003; 5(4): 265–78

Vieta E. The package of care for patients with bipolar depression. J Clin Psychiatry 2005; 66 (5 Suppl.): 34–9

Michalak EE, Yatham LN, Lam RW. The role of psychoeducation in the treatment of bipolar disorder: a clinical perspective. Clin App Bipolar Disord 2004; 3: 5–11

Jones S. Psychotherapy of bipolar disorder: a review. J Affect Disord 2004; 80: 101–14

Dannon PN, Iancu I, Grunhaus L. Psychoeducation in panic disorder patients: effect of a self-information booklet in a randomized, masked-rater study. Depress Anxiety 2002; 16: 71–6

Lukens EP, McFarlane WR. Psychoeducation as evidence-based practice: considerations for practice, research, and policy. Brief Treat Crisis Interv 2004; 4(3): 202–25

Brown NW. Psychoeducational education groups. Philadelphia (PA): Taylor & Francis, 1998

Hayes R, Gant A. Patient psychoeducation: the therapeutic use of knowledge for the mentally ill. Soc Work Health Care 1992; 17(1): 53–67

Geist R, Heinmaa M, Stephens D, et al. Comparisons of family therapy and family group psychoeducation in adolescents with anorexia nervosa. Can J Psychiatry 2000; 45(2): 173–8

Heru AM, Ryan CE, Madrid H. Psychoeducation for caregivers of patients with chronic mood disorders. Bull Menninger Clin 2005; 69(4): 331–40

Hogarty GE, Anderson CM, Reiss DJ, et al. Family psychoeducation, social skills training and maintenance chemotherapy in the aftercare treatment of schizophrenia: I. One-year, effects of a controlled study on relapse and expressed emotion. Arch Gen Psychiatry 1986; 43: 633–42

Colom F, Lam D. Psychoeducation: improving outcomes in bipolar disorder. Eur Psychiatry 2005; 20(5–6): 359–64

Bonaccorso S, Sturchio JL. What information do patients need about medicines? Perspectives from the pharmaceutical industry. BMJ 2003; 327: 863–4

Chambless DL, Ollendick TH. Empirially supported psychological interventions: controversies and evidence. Annu Rev Psychol 2001; 52: 685–716

Devine E, O’Connor F, Cook T, et al. Clinical and financial effects of psychoeducational care provided by staff nurses to adult surgical patients in the post-DRG environment. Am J Public Health 1988; 78(10): 1293–7

Visser A, Snoek F. Perspectives on education and counseling for diabetes patients. Patient Educ Couns 2004; 53: 251–5

Malow RM, Weat JA, Corrigan SA, et al. Outcome of psychoeducation for HIV risk reduction. AIDS Educ Prev 1994; 6(2): 113–25

LeFort SM, Gray-Donald K, Rowat KM, et al. Randomized controlled trial of a community-based psychoeducation program for the self-management of chronic pain. Pain 1998; 74(2–3): 297–306

Katz MR, Irish JC, Devins GM. Development and pilot testing of a psychoeducational intervention for oral cancer patients. Psychooncology 2004; 13(9): 642–53

Commissaris K, Verhey FR, Jolles J. A controlled study into the effects of psychoeducation for patients with cognitive disturbances. J Neuropsychiatry Clin Neurosci 1996; 8(4): 429–35

Davis R, McVey G, Heinmaa M, et al. Sequencing of cognitive-behavioral treatments for bulimia nervosa. Int J Eat Disord 1999; 25(4): 361–74

Rollman BL, Belnap BH, Mazumdar S, et al. A randomized trial to improve the quality of treatment for panic and generalized anxiety disorders in primary care. Arch Gen Psychiatry 2005; 62: 1332–41

Kominars KD. A study of visualization and addiction treatment. Controlled Clin Trial 1997; 14(3): 213–23

Pakkala E, Merinder L. Psychoeducation for schizophrenia. Cochrane Database Syst Rev 2004; 4: 1–76

Sirey JA, Bruce ML, Alexopoulos GS. The treatment initiation program: an intervention to improve depression outcomes in older adults. Am J Psychiatry 2005; 162: 184–6

Colom F, Vieta E. A perspective on the use of psychoeducation, cognitive-behavioral therapy and interpersonal therapy for bipolar patients. Bipolar Disord 2004; 6(6): 480–6

Pound P, Britten N, Myfanwy M, et al. Resisting medicines: a synthesis of qualitative studies of medicine taking. Soc Sci Med 2005; 61: 133–55

de Andres RD, Aillon N, Bardiot MC, et al. Impact of the life goals group therapy program for bipolar patients: an open study. J Affect Disord Jul 2006; 93(1–3): 253–7

Bauer MS, McBride L. Structured group psychotherapy for bipolar disorder: the Life Goals Program. 2nd ed. New York: Springer Publishing Company, 2003

Bauer MS, McBride L, Williford WO, et al. Collaborative care for bipolar disorder: part I. Intervention and implementation in a randomized effectiveness trial. Psychiatr Serv 2006; 57(7): 927–36

Bauer MS, McBride L, Williford WO, et al. Collaborative care for bipolar disorder: part I. Impact on clinical outcome, function and costs. Psychiatr Serv 2006; 57(7): 937–45

Scott J. Treatment outcome studies. In: Johnson SL, Leahy R, editors. Psychological treatment of bipolar. New York: Guilford, 2004: 226–41

Lam DH, Hayward P, Watkins ER, et al. Relapse prevention in patients with bipolar disorder: cognitive therapy outcome after 2 years. Am J Psychiatry 2005 Feb; 162(2): 324–9

Frank E, Swartz HA, Mallinger AG, et al. Adjunctive psychotherapy for bipolar disorder: effects of changing treatment modality. J Abnorm Psychol 1999; 108: 579–87

Rea MM, Thompson M, Miklowitz DJ, et al. Family-focused treatment versus individual treatment for bipolar disorder: results of a randomized clinical trial. J Consult Clin Psychol 2003; 71: 482–92

Miklowitz DJ, Otto MW, Frank E, et al. Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhance ment Program. Arch Gen Psychiatry 2007; 64(4): 419–26

Schotte CKW, Van Den Bossche B, De Doncker D, et al. Biopsychosocial model as a guide for psychoeducation and treatment of depression. Depress Anxiety 2006; 23: 312–24

Romm S, Avery DH, Roy-Byrne PP. Psychological interventions for bipolar disorder in adults: adjunctive outpatient treatments to achieve and maintain remission. Prim Psychiatry 2006; 13(11): 76–81

van Gent EM, Zwart RM. Psychoeducation of partners of bipolar patients. J Affect Disord 1991; 21: 15–8

Fristad MA. Psychoeducational treatment for school-aged children with bipolar disorder. Dev Psychopathol 2006; 18: 1289–306

Scott J, Tacci MJ. A pilot study of concordance therapy for individuals with bipolar disorders who are non-adherent with lithium prophylaxis. Bipolar Disord 2002; 4: 386–92

Makela EH, Griffith RK. Enhancing treatment of bipolar disorder using the patient’s belief system. Ann Pharmacother 2003; 37: 543–5

Byrne MK, Deane FP, Lambert G, et al. Enhancing medication adherence: clinician outcomes from the Medication Alliance training program. Aust N Z J Psychiatry 2004; 38: 246–53

Newell SA, Bowman JA, Cockburn JD. A critical review of interventions to increase compliance with medication taking, obtaining medication refills and appointment keeping in the treatment of cardiovascular disease. Prev Med 1999; 29: 535–48