Factors affecting treatment compliance in patients with bipolar I disorder during prophylaxis: a study from Turkey

doi:10.1016/j.genhosppsych.2013.11.006

General Hospital Psychiatry

Volume 36, Issue 2, March–April 2014, Pages 208-213

https://doi.org/10.1016/j.genhosppsych.2013.11.006 Get rights and content

Abstract

Objectives

Treatment noncompliance is one of the most frequent causes of relapse and recurrence in patients with bipolar I disorder. Treatment compliance among patients with bipolar disorder is affected by individual patients’ features, the disease itself, doctor-patient relationships and patients’ socio-economic and cultural characteristics. This study aimed to determine the factors affecting treatment compliance during the treatment of bipolar disorder and contribute to current clinical strategies.

Methods

Data were collected from 78 volunteers with bipolar I disorder in remission; all volunteers were being treated solely with mood stabilisers. Sociodemographic and clinical data were gathered through a semi-structured interview designed by researchers. The Hamilton Depression Rating Scale and the Young Mania Rating Scale were both administered to assess remission of bipolar I disorder, and a self-report scale, the Medication Adherence Rating Scale, was administered to assess medication adherence.

Results

Treatment compliant patients reported that they had received adequate social support and had been sufficiently informed by their physicians about the illness and treatment. Treatment compliant individuals with higher rates of hospitalisations and the results indicate that the number of depressive episodes adversely affects treatment compliance. There was not a statistically significant difference in treatment compliance based on duration of illness, euthymia, time, total number of episodes, age of onset, predominant polarity, drug doses, number of daily medications, frequency of daily medications, or type of mood stabiliser used.

Conclusions

These results indicate that there are differences between compliant and non-compliant bipolar I disorder patients in terms of adequate social support, information provided by the physician about the illness and treatment, number of depressive episodes and number of hospitalisations.

Introduction

Clinicians agree that treatment compliance is difficult to attain and poses an obstacle to good clinical outcomes among individuals with severe mental disorders [1]. Treatment compliance could be defined as the patient’s acceptance of the essential health and treatment proposals and conformity with them; this definition includes a number of behaviours, such as accessing treatment, accepting medication, understanding follow-up advice and remembering to take medication. This definition, which cannot be limited to describing the usage of prescribed medications, also describes the entire set of proposals made by the clinician, including in behavioural aspects [2], [3], [4], [5]. The term “treatment compliance” is more comprehensive than “medication adherence,” a term referring only to prescribed medications.

Psychopharmacology has significant importance in the treatment of bipolar I disorder (BPD), both in the acute and maintenance therapy periods. Immediately after an acute episode, many patients require long-term prophylaxis to prevent recurrence. Despite new psychopharmacological developments, treatment outcomes still depend upon treatment compliance. Treatment noncompliance is one of the most frequent causes of relapse and recurrence in BPD patients and is linked to adverse outcomes, such as increased polyclinical applications, rehospitalisation, poor community adjustment [6] and suicide [2], [7], [8], [9], [10]. These outcomes are also indicators of increased health care utilisation and cost of health services [11]. The potential benefits of pharmacological treatment, including recovery, relapse prevention and reduced mortality, decrease greatly with noncompliance [2], [3]. The reported noncompliance rates for long-term prophylactic pharmacotherapy for BPD range from 20% to 66%; the mean prevalence is noted to be 41% [2], [3], [4].

Thus far, the factors affecting treatment compliance among patients with BPD have not been determined. Many variables related to the patient (socioeconomic characteristics, perceptions, beliefs), clinician (the relationship between physician and patient), treatment (efficacy, side effects, drug dose, number of pills, number of medications) and the disorder itself (illness severity, symptom frequency, comorbidity) may be involved. Any of these risk factors could encourage noncompliance, either by themselves or by interacting with the other factors; however, most of them seem suitable for intervention. Therefore, the variables that increase or decrease compliance levels must be researched to develop new clinical strategies [3], [12], [13], [14], [15], [16], [17].

In this study, the aim was to determine the factors affecting treatment adherence among BPD patients, especially in Turkey, and contribute to the repertoire of clinical strategies.

Section snippets

Selection of subjects and stages of the study

This study was carried out with patients recruited from the out-patient unit of the Psychiatry Department of Yildirim Beyazit University’s Ankara Ataturk Research and Training Hospital. After obtaining the ethics committee’s approval, patients diagnosed with BPD I (based on a structured clinical interview for DSM-IV disorders) who were hospitalized in the clinic were reached by phone regarding the study, and face-to-face interviews were conducted. Subjects were between the ages of 18 and 65 and

Confirmatory factor analysis of medication adherence rating scale

To test the reliability of the 10-item scale used with this study sample, the internal consistency was evaluated, and the Cronbach’s alpha coefficient was calculated to be 0.735. Similarly, the construct validity was evaluated to determine the validity of the scale, and the confirmatory factor analysis showed that the chi-square was (CMIN) 56.019, with 35 degrees of freedom (df); also, the CMIN/df was 1.601, the Goodness of Fit Index was 0.874 and the root mean square error of approximation was

Discussion

In previous studies, it was reported that the noncompliance rate among BPD patients ranged from 20% to 66% and that the mean prevalence was 44% [2], [3], [4]. The current study’s rates are similar to those studies [1], [10]. There is no generally accepted method of measuring compliance to treatment among patients with bipolar disorder. Generally, the most commonly used measures of treatment compliance are self-reports and plasma levels [22], [23]. Self-report scales provide a non-invasive

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The problems and information needs of patients with bipolar disorder during the treatment process: A qualitative study in Turkey
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Citation Excerpt :
As Horne (2006) notes, most people tend to evaluate a recommended course of treatment according to whether the recommendations make sense based on their personal experience, their beliefs about their illness or health conditions, and their expectations for treatment. Although the importance of drugs has been emphasized in the current clinical guideline, the non-compliance rate in patients with BD has varied between 20 % and 66 %, and this has been an important problem that requires hospitalization of the patient again (Col et al., 2014; Jawad et al., 2018; Manhas et al., 2019; Vedanarayanan et al., 2019). These problems have been thought to be the main causes of the recurrence of the disease (Savas et al., 2011).
The objective of the present study was to determine the problems and information needs of patients with bipolar disorder during the treatment process. The present research is in the type of descriptive and qualitative study. In-depth individual interviews were conducted with 11 volunteer patients with bipolar disorder. The data collected from the interviews were evaluated using the descriptive analysis method. In the study, four categories (disease onset/diagnosis stage, adherence to treatment, interpersonal relationships, information needs) and nine main themes (symptoms, family support, factors that positively affect treatment adherence, factors that negatively affect treatment adherence, positive effects of treatment, negative effects of treatment, stigmatization, treatment, disease) were determined. Patients with bipolar disorder can be helped to cope with the problems they experience by providing information about the disease, adherence to treatment, the treatment process, and the effects of drugs.
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In the study conducted in eight European countries, 57% of bipolar patients were reported to be partially or completely non-adherent with the medication [10]. Col et al. reported in 2014 that 42.3% of the outpatients diagnosed with Bipolar I disorder were non-adherent with the medication [11]. Mert et al. (2015) determined that the rate of medication non-adherence was 45.5% in patients with bipolar disorder six months before hospitalization [7].
and purpose: Treatment non-adherence is quite common among patients with bipolar disorder, negatively affects the social functioning of patients and reduces the quality of life. This pilot study aims to measure the effect of treatment adherence training given to patients with bipolar disorder on treatment adherence, social functioning and quality of life.
The pilot study was conducted with 40 bipolar disorder patients, 19 in the intervention group and 21 in the control group, using a quasi-experimental research design. The data were collected using the Participant Information Form, Medication Adherence Rating Scale, Social Functioning Scale and Short Form of the World Health Organization Quality of Life Questionnaire. Treatment adherence training was given once a week individually for a total of five sessions.
There was no significant difference between the demographic characteristics and pre-test scale scores of the patients in the intervention and control groups before the treatment adherence training (p > 0.05). The mean treatment adherence, social functioning and quality of life scores of the patients in the intervention group were higher in the post-test and follow-up test compared to the patients in the control group (p < 0.001).
The intervention had a positive effect on treatment adherence, social functioning and quality of life of patients. Considering the promising results of this pilot study, treatment adherence training should be studied further in the patients with biplor disorder.
Self-reported medication adherence and its correlates in a lithium-maintained cohort with bipolar disorder at a tertiary care centre in India
2019, Asian Journal of Psychiatry
Citation Excerpt :
These findings from lithium-maintained patients are broadly in consonance with the available literature on treatment adherence in BD in general, with some important differences (e.g. no relationship to duration of illness or duration of treatment). In existing literature, factors associated with non-adherence in BD patients include a younger age, low education status, fewer out-patient visits, early course (1 st year of illness), a longer duration of treatment, denial of illness, real or perceived side-effects, polypharmacy, lack of information, negative attitudes, lack of social support or substance use (Bates et al., 2010; Busby and Sajatovic, 2010; Clatworth et al., 2007; Col et al., 2014; Leclerc et al., 2013; Sajatovic et al., 2015). The present study did not find a relationship of adherence with age, education level or gender in this sample of lithium-maintained patients with BD.
Lithium remains a cornerstone of prophylaxis in bipolar disorder (BD), but adherence continues to be a major clinical challenge and merits a closer attention. There is scant literature available in Indian as well as Asian context.
This study was conducted at Department of Psychiatry, AIIMS, New Delhi with an aim to assess the self-reported medication adherence and its correlates among a naturalistic, lithium-maintained cohort (n = 76) with bipolar disorder. Subjects were included if they were on lithium therapy ≥1 year, met DSM-5 diagnosis of bipolar disorder and were in clinical remission (≥1 month). Besides sociodemographic and clinical performa, participants were assessed on medication adherence rating scale (MARS), lithium questionnaire for knowledge and lithium attitude questionnaire (LAQ).
Mean age was 35.7 ± 10.6 years (males: 59.2%); median duration of illness and lithium therapy was 84 months and 24.5 months, respectively. Mean MARS score was 6.95 ± 2.81. Regression analysis (with MARS total as dependent variable) found LAQ score to be the single most significant predictor variable (β=−0.681, p < 0.0001), explaining over 75% of the total variance. In regression model with MARS factor-1 score as dependent variable, the 'LAQ score' (β=−0.601, p < 0.0001) and 'being accompanied by family during psychiatric visits (always/mostly) in the past year' (β = 0.193, p = 0.010) emerged as significant predictor variables.
Adherence in lithium-maintained treatment-seeking cohort of patients with BD remains far from ideal as observed in this naturalistic setting. Lithium-related attitudes and being accompanied by family during psychiatric visits were found to be significant predictors for adherence.
Bipolar disorder in Asia: Illness course and contributing factors
2017, Asian Journal of Psychiatry
Citation Excerpt :
Additionally, various illness-related factors (Chopra et al., 2006; Hapangama et al., 2013; Moon et al., 2012; Oflaz et al., 2015; Yen et al., 2005), and patient-related factors such as ignorance about side effects (Bener et al., 2013) and forgetfulness (Subramanian et al., 2016; Taj et al., 2008) are oft-quoted reasons for patient’s poor adherence attitudes. Higher levels of education (Ozerdem et al., 2001), adequate social support (Bener et al., 2013; Col et al., 2014) and sufficient illness psychoeducation (Col et al., 2014) led to better adherence rates. The findings from the Asian studies are depicted in Table 5.
Epidemiological studies analysing the course of Bipolar Disorder (BD) are relatively rare in the Asian context, contributing to the uncertainty regarding the prevalent course patterns and factors influencing such patterns. The current review identifies the regional characteristics of BD course patterns and the associated factors.
A review of the existing literature was done using ‘PubMed’ and ‘Cochrane’ databases which yielded 145 studies including those from all 48 Asian countries. Relevant discussions from the Western literature were incorporated.
Regional and cross-national studies reveal a mania-predominant course in BD in Asian countries. Prolonged depressive episodes and comorbid anxiety disorders worsen the course of BD-II. Certain risk factors such as the young age of onset and greater episode frequency are useful predictors of bipolar diatheses. Substance use disorder comorbidity is more prevalent in males whereas depression and suicidal behaviours are more frequent in females with BD. Comorbid anxiety and personality disorders also encumber the illness course. Logistic reasons and ignorance of side-effects were specifically associated with poor adherence. An ‘eveningness’ chronotype and poor sleep quality were associated with frequent recurrences. Seasonal patterns vary among men and women, especially for depressive episodes.
The effects of treatment and childhood BD course features were not discussed.
There are region-specific characteristics in bipolar illness course and factors influencing such course patterns compared to the rest of the World. Future research from Asia shall attempt to study the neurobiological underpinnings of such characteristics and plan appropriate strategies to address the same.
The Relationship Between Treatment Adherence and Social Support in Psychiatric Patients in the East of Turkey
2017, Archives of Psychiatric Nursing
Citation Excerpt :
In the study; adherence to treatment was determined higher in young patients than old patients, men than women, married patients than single or divorced patients, patients with a high educational level than those with a low educational level and patients living in provinces and districts than those living in towns/villages, compared to other demographic characteristics of patients in a statistically nonsignificant way (Table 3). In parallel with the study, Col et al. conducted a study with 78 patients and determined that as the educational level increased, adherence to treatment increased initially and decreased afterward (Col, Caykoylu, Ugurlu, & Ugurlu, 2014). Examining the demographic characteristics of patients, subscales of social support and total score in the study; a significant difference was observed between patients' marital status, people they lived with, place where they lived, level of income and the subscales of social support (p < 0.05).
This study was conducted to determine the relationship between the adherence to treatment and social support in psychiatric patients. The study was completed with a total of 324 psychiatric patients. The data gathering tools used were Demographics Questionnaire, Morisky Medication Adherence Scale and Multi-Dimensional Scale of Perceived Social Support. The study sample consisted of psychiatric patients who were selected from the population by using the simple random sampling method. Among the patients, 50.9% adhered to the treatment, and 14.5% did not. Patients living in city and country-town, with high income and living with family were found to have more social support. A positive, significant relationship was found among scales (p < 0.05). As the mean scores of social support increased, patients' adherence to treatment increased.
Mapping modifiable determinants of medication adherence in bipolar disorder (BD) to the theoretical domains framework (TDF): A systematic review
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Original ContributionFactors affecting treatment compliance in patients with bipolar I disorder during prophylaxis: a study from Turkey

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Selection of subjects and stages of the study

Confirmatory factor analysis of medication adherence rating scale

Discussion

Compr Psychiatry

Clin Ther

Schizophr Res

Int J Nurs Stud

J Affect Disord

J Affect Disord

J Pediatr

Soc Sci Med (1982)

J Affect Disord

J Affect Disord

J Affect Disord

Biol Psychiatry

Factors associated with prospective long-term treatment adherence among individuals with bipolar disorder

Psychiatr Serv (Washington, DC)

Treatment non-adherence in affective disorders

Acta Psychiatr Scand

Enhancing medication adherence in patients with bipolar disorder

Hum Psychopharmacol

Improving treatment adherence in bipolar disorder through psychoeducation

J Clin Psychiatry

Improving treatment adherence in bipolar disorder: a review of current psychosocial treatment efficacy and recommendations for future treatment development

Behav Modif

Level of compliance and factors associated with non-compliance to treatment among the mentally ill patients

Health Renaissance

Enhancement of treatment adherence among patients with bipolar disorder

Psychiatr Serv (Washington, DC)

Suicidal risk in bipolar I disorder patients and adherence to long-term lithium treatment

Bipolar Disord

Effects of lithium treatment and its discontinuation on suicidal behavior in bipolar manic-depressive disorders

J Clin Psychiatry

Age comparison of treatment adherence with antipsychotic medications among individuals with bipolar disorder

Int J Geriatr Psychiatry

Treatment adherence with lithium and anticonvulsant medications among patients with bipolar disorder

Psychiatr Serv (Washington, DC)

Original Contribution
Factors affecting treatment compliance in patients with bipolar I disorder during prophylaxis: a study from Turkey