Understanding different beliefs held by adherers, unintentional nonadherers, and intentional nonadherers: application of the Necessity-Concerns Framework

OBJECTIVE: The objective of this study was to explore beliefs about medicines, using the Necessity-Concerns Framework, of patients who report adherence, unintentional nonadherence, and intentional nonadherence. METHOD: This study performed a cross-sectional survey of patients starting a new medication for a chronic condition. Self-reported adherence was assessed via telephone interview. The Necessity-Concerns Framework was operationalized using the Beliefs About Medicines Questionnaire, which assesses beliefs about the necessity of and concerns with taking medications. RESULTS: Intentional nonadherers, compared to adherers, had lower perceptions of the necessity of their new medication and higher levels of concerns about taking it. Conversely, unintentional nonadherers were not significantly different from adherers. Intentional nonadherers were more likely to rate their concerns as high relative to their need for treatment than both adherers and unintentional nonadherers. CONCLUSION: When patients start a new medication for a chronic condition, intentional nonadherers hold beliefs significantly different from those of adherers and unintentional nonadherers. These findings have implications for practice in helping clinicians to reduce this type of nonadherence.     

Secondary prevention of coronary heart disease: patient beliefs and health-related behaviour

OBJECTIVE: Coronary heart disease (CHD) is a leading cause of illness and death in Western society. The present study was designed to evaluate the utility of illness perceptions and medication beliefs in predicting secondary preventive behaviour among patients with CHD. An extended version of Leventhal's self-regulatory model (SRM) was used as a theoretical framework for this study [Leventhal H, Nerenz DR, Steele DJ. Illness perceptions and coping with health threat. In: Baum A, Taylor SE, Singer JE, editors. Handbook of psychology and health, Volume IV: social psychological aspects of health. Hillsdale (NJ): Erlbaum, 1984. pp. 219-52; Horne R, Weinman J. Self-regulation and self-management in asthma: exploring the role of illness perceptions and treatment beliefs in explaining non-adherence to preventer medication. Psychol Health 2002;17(1):17-32]. METHOD: Medical and demographic data were gathered from the medical charts of 1611 patients with established CHD from 35 randomly selected general practices. Self-report data about patients' lifestyles (diet, exercise, smoking, alcohol consumption and medication adherence) and information on illness and medication beliefs were provided from postal questionnaire (1084 patients responded; 69% response rate). The relationship between patients' beliefs and their secondary preventive behaviour was examined using regression analyses. RESULTS: Illness perceptions appeared to be only weak predictors of smoking, exercise, diet, alcohol consumption and medication adherence, accounting for about 2% of the variance in these behaviours. Medication beliefs were moderately related to medication adherence, accounting for about 7% of the variance in scores. A strong belief in the necessity of one's medication and a lower level of concern about one's medication were associated with higher levels of adherence. CONCLUSIONS: An illness perception approach did not prove helpful in predicting secondary preventive behaviour among this group of patients. However, beliefs about medications appear to be reasonable predictive of medication adherence.     

Treatment-adherence in bipolar disorder: A patient-centred approach

About half of the patients diagnosed with bipolar disorder (BD) become non-adherent during long-term treatment, a rate largely similar to other chronic illnesses and one that has remained unchanged over the years. Non-adherence in BD is a complex phenomenon determined by a multitude of influences. However, there is considerable uncertainty about the key determinants of non-adherence in BD. Initial research on non-adherence in BD mostly limited itself to examining demographic, clinical and medication-related factors impacting adherence. However, because of inconsistent results and failure of these studies to address the complexities of adherence behaviour, demographic and illness-related factors were alone unable to explain or predict non-adherence in BD. This prompted a shift to a more patient-centred approach of viewing non-adherence. The central element of this approach includes an emphasis on patients’ decisions regarding their own treatment based on their personal beliefs, life circumstances and their perceptions of benefits and disadvantages of treatment. Patients’ decision-making processes are influenced by the nature of their relationship with clinicians and the health-care system and by people in their immediate environment. The primacy of the patient’s perspective on non-adherence is in keeping with the current theoretical models and concordance-based approaches to adherence behaviour in BD. Research over the past two decades has further endorsed the critical role of patients’ attitudes and beliefs regarding medications, the importance of a collaborative treatment-alliance, the influence of the family, and the significance of other patient-related factors such as knowledge, stigma, patient satisfaction and access to treatment in determining non-adherence in BD. Though simply moving from an illness-centred to a patient-centred approach is unlikely to solve the problem of non-adherence in BD, such an approach is more likely to lead to a better understanding of non-adherence and more likely to yield effective solutions to tackle this common and distressing problem afflicting patients with BD.     

Patients' beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness

The aim of this cross-sectional study was to quantify patients' personal beliefs about the necessity of their prescribed medication and their concerns about taking it and to assess relations between beliefs and reported adherence among 324 patients from four chronic illness groups (asthma, renal, cardiac, and oncology). The findings revealed considerable variation in reported adherence and beliefs about medicines within and between illness groups. Most patients (89%) believed that their prescribed medication was necessary for maintaining health. However, over a third had strong concerns about their medication based on beliefs about the dangers of dependence or long-term effects. Beliefs about medicines were related to reported adherence: higher necessity scores correlated with higher reported adherence (r=0.21, n=324, p<0.01) and higher concerns correlated with lower reported adherence (r=0.33, n=324, p<0.01). For 17% of the total sample, concerns scores exceeded necessity scores and these patients reported significantly lower adherence rates (t=-4.28, p<0.001). Stepwise multiple linear regression analysis showed that higher reported adherence rates were associated with higher necessity-concerns difference scores (beta=0.35, p<0.001), a diagnosis of asthma (beta= -0.31, p<0.001), a diagnosis of heart disease (beta=0.19, p<0.001), and age (beta=0.22, p<0.001). Gender, educational experience, or the number of prescribed medicines did not predict reported adherence. Medication beliefs were more powerful predictors of reported adherence than the clinical and sociodemographic factors, accounting for 19% of the explained variance in adherence. These data were consistent with the hypothesis that many patients engage in an implicit cost-benefit analysis in which beliefs about the necessity of their medication are weighed against concerns about the potential adverse effects of taking it and that these beliefs are related to medication adherence.     

Factors related to medication adherence in memory disorder clinic patients

Medication adherence is a substantial problem in the elderly. It may be even more important among elderly persons with memory problems, since other factors that lead to non-adherence may be compounded with the memory problems themselves. The objective was to determine whether a model that integrates research on medication adherence from several research domains is useful in understanding adherence in elderly patients. The methodology involved a cross-sectional observational study using a convenience sample of 63 patients drawn from a university-affiliated outpatient memory disorders clinic. The primary measure of medication adherence was caregivers' reports of patients' medication adherence. Patients and their caregivers were asked questions assessing their beliefs about the seriousness of each condition for which a medication was prescribed and the likely outcome of that condition without treatment. Additional data collected included presence of side effects, total number of medications taken, and patients' mood and cognitive status. Multilevel path analysis confirmed several model-based predictions. Caregivers' reports of adherence were predicted by estimates of disease outcome, the presence of side effects, and patients' relying on themselves to remember to take medications. Results partially confirm the integrative model in understanding medication adherence in these patients. Patients' beliefs about the likely effect of medication treatment for their condition and the presence of side effects influence reported medication adherence. Results thus suggest that efforts to educate patients about the likely response of their medical condition to treatment and to assess and deal with medication side effects might improve patient adherence.     

Predictors of antipsychotic medication adherence in patients recovering from a first psychotic episode

BACKGROUND: Many patients recovering from a first psychotic episode will discontinue medication against medical advice, even before a 1-year treatment course is completed. Factors associated with treatment adherence in patients with chronic schizophrenia include beliefs about severity of illness and need for treatment, treatment with typical versus atypical antipsychotic and medication side effects. METHOD: In this 2-year prospective study of 254 patients recovering from a first episode of schizophrenia, schizophreniform, or schizoaffective disorder we examined the relationship between antipsychotic medication non-adherence and patient beliefs about: need for treatment, antipsychotic medication benefits, and negative aspects of antipsychotic medication treatment. We also examined the relationship between medication non-adherence and treatment with either haloperidol or olanzapine, and objective measures of symptom response and side effects. RESULTS: The likelihood of becoming medication non-adherent for 1 week or longer was greater in subjects whose belief in need for treatment was less (HR=1.75, 95% CI 1.16, 2.65, p=0.0077) or who believed medications were of low benefit (HR=2.88, 95 CI 1.79-4.65, p<0.0001). Subjects randomized to haloperidol were more likely to become medication non-adherent for >or=1 week than subjects randomized to olanzapine (HR-1.51, 95% CI 1.01, 2.27, p=0.045). CONCLUSION: Beliefs about need for treatment and the benefits of antipsychotic medication may be intervention targets to improve likelihood of long-term medication adherence in patients recovering from a first episode of schizophrenia, schizoaffective, or schizophreniform disorder.     

Non-adherence to Immunosuppressive Medications in Kidney Transplantation: Intent Vs. Forgetfulness and Clinical Markers of Medication Intake

Background

Although adherence to immunosupressive medication after transplantation is important to maximize good clinical outcomes it remains suboptimal and not well-understood. The purpose of this study was to examine intentional and unintentional non-adherence to immunosuppression medication in kidney transplant patients.

Methods

A cross-sectional sample of N?=?218 patients [49.6?±?12.3?years] recruited in London, UK (1999?C2002) completed measures of medication beliefs, quality-of-life, depression, and transplantation-specific emotions. Adherence was measured with self-report and serial immunosuppressive assays.

Results

Intentional non-adherence was low (13.8?%) yet 62.4?% admitted unintentional non-adherence and 25.4?% had sub-target immunosuppressive levels. The risk of sub-target serum immunosuppressive levels was greater for patients admitting unintentional non-adherence (OR?=?8.4; p?=?0.004). Dialysis vintage, doubts about necessity, and lower worry about viability of graft explained R ²?=?16.1 to 36?% of self-report non-adherence. Depression was related only to intentional non-adherence.

Conclusions

Non-adherence is common in kidney transplantation. Efforts to increase adherence should be implemented by targeting necessity beliefs, monitoring depression, and promoting strategies to decrease forgetfulness.     

A collaborative approach to the treatment alliance in bipolar disorder

OBJECTIVES: The treatment alliance is the arena in which psychopharmacological and other therapeutic interventions occur. The nature and quality of the treatment alliance may affect adherence to treatment and the realization of the benefits of effective pharmacological treatment in clinical practice. It is an area that has attracted little systematic study, despite the available evidence suggesting that it plays a measurable role in clinical outcomes. METHODS: A literature search was undertaken using Medline, Ovid, Psychinfo and Science Direct from 1975 to 2004. The following key words were used: bipolar disorder, patient adherence, non-adherence to medication, compliance, doctor-patient relationship, doctor-patient communication, treatment alliance, therapeutic alliance, chronic illness management, collaborative care, self-management, health beliefs, self-efficacy, self-determination, autonomy support, motivational interviewing. RESULTS: Psychosocial interventions have demonstrated positive effects on adherence problems. Studies of the impact of the treatment alliance on outcomes in mental illness highlight the possibilities of fruitful research in this area in bipolar disorder. Different theoretical models of changing health related behaviour may inform approaches to the treatment alliance. CONCLUSIONS: Results suggest the usefulness of a collaborative approach to the treatment alliance. Attention needs to be given to developing intervention models that target modifiable risk factors for non-adherence and address patient, clinician and illness related variables to enhance medication adherence in the treatment alliance. Refinement of these models through controlled evaluation in real world settings may lead to integration in health care delivery systems.     

Treatment adherence with antipsychotic medications in bipolar disorder

OBJECTIVES: Atypical antipsychotic medications are a relatively new, increasingly prominent component of the treatment armamentarium for bipolar disorder. Information on adherence with antipsychotics among individuals with bipolar disorder in general, and atypical antipsychotics in particular, is currently quite limited. Using data from the VA National Psychosis Registry, we examined adherence with antipsychotic medications among patients with bipolar disorder (n = 73,964). METHODS: Antipsychotic medication adherence among veterans with bipolar disorder was evaluated using the medication possession ratio and categorizing patients into three groups: fully adherent, partially adherent and non-adherent. We compared characteristics of bipolar patients who received versus those who did not receive antipsychotic medication, and also identified predictors of poor adherence with antipsychotic medications. RESULTS: Approximately 45% (n = 32,993) of all individuals with bipolar disorder were prescribed antipsychotic medication. Individuals who were prescribed antipsychotic medications were younger and more often had comorbid substance abuse or post-traumatic stress disorder compared to individuals with bipolar disorder who were not prescribed antipsychotic medication. Just over half (51.9%) of individuals appear to be fully adherent with antipsychotic medications, while 48.1% of individuals are either partially adherent or non-adherent with antipsychotic medications. Factors associated with treatment non-adherence were younger age, minority ethnicity, comorbid substance abuse and homelessness. CONCLUSIONS: Treatment non-adherence is a major issue for close to half of individuals with bipolar disorder prescribed antipsychotic medication. Additional studies are needed to better understand treatment adherence within the full range of pharmacologic therapies among individuals with bipolar disorder.     

Physical symptoms,beliefs about medications,negative mood,and long-term HIV medication adherence

Background: Near-perfect levels of HIV medication adherence are necessary for treatment to be successful. However, many patients continue to report nonadherence to HIV treatment.Purpose: This study examines the relationship between symptoms of HIV and medication adherence and evaluates beliefs about HIV medications and negative mood states as potential mediators of this relationship.Methods: These relationships were tested with structural equation modeling using a 15-month longitudinal design. The ethnically diverse convenience sample included 325 HIV-infected men who have sex with men and women prescribed Highly Active Antiretroviral Therapy (HAART).Results: Results showed that a greater number of symptoms were associated with poorer medication adherence, and this relationship was partially mediated by increases in concerns about HAART. Contrary to expectations, negative mood states were not directly related to medication adherence. In the final model, concerns about HAART and general distrust of medications each predicted poorer HAART adherence. Necessity beliefs about HAART and level of educational attainment each predicted better adherence. The final model accounted for approximately 24% of the variance in HAART adherence.Conclusions: The results of this study suggest that Horne’s (1) necessity-concerns framework can be successfully applied to identify beliefs about medication that are important predictors of adherence to HAART over time. These findings have relevance for developing interventions to improve medication adherence among HIV-infected patients. This research was supported by grants from the National Institute of Mental Health (P01 MH49548 and T32 MH18917).     

Adherence to treatment in patients with epilepsy: associations with seizure control and illness beliefs.

OBJECTIVE: This study investigated non-adherence to antiepileptic drug treatment amongst patients with epilepsy in secondary care. The associations between adherence and seizure control, perceptions of illness and medication, anxiety and depression were also examined. METHODS: A cross-sectional study of fifty-four patients with epilepsy were recruited from a hospital epilepsy clinic. RESULTS: Fifty-nine percent were estimated to be non-adherent to medication. There was a negative correlation between adherence and frequency of seizures. Patients with poorly controlled epilepsy were more anxious, and expected a longer duration of their epilepsy. CONCLUSION: Assessment of adherence should be a routine part of management of epilepsy. Further recognition and support should be given to patients who have poor seizure control since they are more likely to be more anxious and have unhelpful illness and treatment beliefs.     

Detection of non-adherent behaviour in early psychosis

OBJECTIVE: Adherence to antipsychotic treatment is an important aspect of the long-term management of schizophrenia. The evaluation of adherence is often difficult in the clinical setting. This study compared patient self-reporting and clinician judgment of adherence behaviour in patients with early and chronic schizophrenia. METHOD: Clinician-rated questionnaires and parallel patient self-rated questionnaires were administered to 229 patients with early schizophrenia (illness duration < 5 years) and 255 patients with chronic schizophrenia. Items in the questionnaires addressed two forms of adherence behaviour (forgetting to take medication and deciding to stop medication) as well as attitudes toward medication. RESULTS: Significant non-adherent behaviour was reported by patients, particularly in the early schizophrenia group. Non-adherent behaviour was related to feelings of embarrassment about taking medication. Both non-adherence and embarrassment were under-recognized by clinicians. Starting from a prior probability of 0.24, knowledge of the patients' attitudes increased the posterior probability to 0.33, whereas clinicians' detection of non-adherence (deciding to stop medication) improved the posterior probability to 0.65. When both clinicians' evaluations and patients' attitudes were known, the posterior probability improved to 0.68. CONCLUSION: Non-adherence is a widespread phenomenon in early schizophrenia. Increasing clinicians' sensitivity to patients' feelings of embarrassment may be an important factor in the detection of non-adherence. When taking a base rate of non-adherence into consideration, clinicians' evaluations appeared to be more effective in detecting non-adherence than simple information obtained from patients on their attitudes toward medication. Pragmatic real-life estimation of non-adherence has important implications for the possibility of intervention.     

Are we addressing the 'right stuff' to enhance adherence in schizophrenia? Understanding the role of insight and attitudes towards medication

Background

Despite the fact that medication adherence is among the most important health related behaviors in relapse prevention and recovery in schizophrenia, it is often not sufficiently endorsed by patients. Poor insight and negative attitudes towards medication are risk factors for non-adherence. Their relationship and the influence of more general attitudes towards pharmacotherapy besides attitudes towards antipsychotics have not been fully understood. The present study investigated whether these factors independently influence adherence or whether they mediate one another.

Methods

A cross-sectional sample of 150 outpatients completed the Beliefs about Medication Questionnaire. It assesses patients' beliefs about antipsychotic medication in terms of necessity and concerns and more general beliefs about pharmacotherapy in terms of distrust. Additionally, the patients' global awareness of illness (Scale to assess Unawareness of Mental Disorder), and medication adherence (Brief Adherence Rating Scale, Service Engagement Scale) were assessed.

Results

Using structural equation modeling, the study found evidence for a mediational model. Awareness of illness contributed to medication adherence via patients' perceived necessity of antipsychotics. The model further revealed a direct negative relationship between concerns regarding antipsychotics and adherence and an indirect negative effect of a general distrust regarding pharmacotherapy and adherence via antipsychotic specific attitudes.

Conclusion

Interventions to enhance medication adherence may be more effective if they focus on treatment related attitudes rather than on global insight into illness. Clinicians may not only enhance the patients' perceived necessity of antipsychotic treatment but also explore and address concerns and the patients' distrust in pharmacotherapy in a more personalized way.     

Non–adherence to aspirin or oral anticoagulants in secondary prevention after ischaemic stroke

BACKGROUND : The effectiveness of medication is influenced by treatment adherence. After TIA or minor disabling stroke patients usually are advised to take antithrombotic medication. Stroke patients are an interesting group of patients with respect to adherence, since cardiovascular risk factors and stroke may (indirectly) negatively influence brain function, which can affect adherence. We investigated determinants of non-adherence in patients who used aspirin or oral anticoagulation after cerebral ischaemia of arterial origin. METHODS : Data of patients prospectively followed in two clinical trials (the Dutch TIA Trial and the Stroke Prevention In Reversible Ischaemia Trial) were analysed with Cox proportional hazards modelling. RESULTS : In the two trials 3796 patients were treated with aspirin. During a mean follow-up of 2.1 years, 689 patients (18%) prematurely stopped treatment, 305 (8 %) did so without a clear medical reason (non-adherence). Age >or= 65 years and the use of 300 instead of 30 mg of aspirin were independently associated with non-adherence. Diastolic blood pressure of >or= 90 mmHg and dizziness were associated with better adherence. Of 651 patients on oral anticoagulation, 143 patients (22 %) stopped after a mean follow-up of 1.0 year, 66 (10 %) did so because of nonadherence. No statistically significant determinants for non-adherence were identified. CONCLUSION : As found in the literature on nonadherence in general, age of >or= 65 years and a higher dose of aspirin (300 mg versus 30 mg) were independently associated with non-adherence with aspirin treatment that was prescribed for secondary prevention after cerebral ischaemia of arterial origin. Older patients may require extra encouragement to continue antithrombotic treatment. Lower doses of aspirin may improve treatment adherence.     

Identifying psychosocial predictors of medication non-adherence following acute coronary syndrome: A systematic review and meta-analysis

ObjectiveMedication non-adherence following acute coronary syndrome (ACS) is associated with poor clinical outcomes. A systematic review and meta-analysis were undertaken to identify psychosocial factors associated with medication adherence in patients with ACS.MethodsA search of electronic databases (Cochrane Library, Medline, EMBASE, PsycINFO, Web of Science, International Pharmaceutical Abstracts, CINAHL, ASSIA, OpenGrey, EthOS and WorldCat) was undertaken to identify relevant articles published in English between 2000 and 2014. Articles were screened against our inclusion criteria and data on study design, sample characteristics, predictors, outcomes, analyses, key findings and study limitations were abstracted.ResultsOur search identified 3609 records, of which 17 articles met our inclusion criteria (15 independent studies). Eight out of ten studies found an association between depression and non-adherence. A meta-analysis revealed that depressed patients were twice as likely to be non-adherent compared to patients without depression (OR = 2.00, 95% CI 1.57–3.33, p = 0.015). Type D personality was found to predict non-adherence in both studies in which it was measured. Three out of three studies reported that treatment beliefs based on the Necessity-Concerns Framework predicted medication non-adherence and there was some evidence that social support was associated with better adherence. There was insufficient data to meta-analyse all other psychosocial factors identified.ConclusionThere was some evidence that psychosocial factors, particularly depression, were associated with medication adherence following ACS. Targeting depressive symptoms, screening for Type D personality, challenging maladaptive treatment beliefs, and providing better social support for patients may be useful strategies to improve medication adherence.     

Use of Prescription Medication by Individuals Who Died by Suicide in Northern Ireland

To understand medication use prior to suicide in relation to patterns, polypharmacy, and adherence. A total of 1,371 suicide cases were coded and latent class analysis used to identify combinations of medications prescribed prior to death. Two thirds had been prescribed medication with 30.7% prescribed 3 or more. Latent class analysis revealed three classes: Mixed medication use, primarily mental medication use, and baseline/low medication use. There are potentially high rates of medication non-adherence. Not only medication use but also non-adherence rates were high in this sample of individuals who died by suicide. Potential implications and areas for future research are discussed.     

Perceived coercion at hospital admission and adherence to mental health treatment after discharge

The authors investigated whether mental health inpatients' perceptions of coercion were associated with later treatment adherence. Psychiatric inpatients receiving acute care at three sites were interviewed during their hospitalization and up to five times after discharge. Patients' perceptions of coercion were measured at admission. Adherence to medication and clinical treatment was measured every ten weeks for one year after discharge. Among the 825 patients who had a perceived coercion score and ten-week follow-up data and who reported that outpatient treatment was prescribed, perceived coercion scores were not associated with treatment adherence. The authors concluded that perceived coercion neither increases nor decreases psychiatric inpatients' medication adherence or use of treatment services after discharge.