Knowledge and compliance towards lithium therapy among Chinese psychiatric patients in Hong Kong.

Although patient education is believed to promote medication compliance, the exact relationship between the acquisition of drug knowledge and compliance during lithium treatment is unclear. A survey of 50 Chinese patients on maintenance lithium therapy revealed that their medical knowledge about lithium treatment, as measured by a "Lithium Questionnaire," was very limited. Nonetheless, 70% of these patients were found, by multiple criteria, to be good compliers, and lithium compliance was apparently not affected by the amount of drug knowledge that patients possessed. It is argued that in the process of conducting patient education to enhance lithium compliance, a sound therapeutic alliance is more important than sheer knowledge acquisition.     

Enquête sur la perception de l'observance dans la schizophrénie (EPOS)

From the patient's viewpoint, good quality compliance supposes a good relationship with his/her doctor; this relationship is directly linked to the therapist's heeding and interest shown to the patient, and not to the patient's symptoms alone. If individual motivation plays an important part at the outset, it will nevertheless be seriously influenced by the relationship between the doctor and his/her patient. It is one of the rare factors for which a positive correlation with compliance can be observed, as shown by practically all medical psychology research. To these well-known classical medical notions correspond average values of non-compliance, which may vary widely according to those concerned. These data are proof of the wide gap existing between what is expected and what is actually achieved. This discrepancy is felt by the patient as well as by his/her therapist, and involves many other factors linked to culture, to medical and religious background, medical anthropology, and the real or supposed proprieties of the Pharmakon. Compliance to antipsychotic medication in schizophrenia continues to be a significant and challenging question in terms of its prevalence as well as its significant impact on the rate of relapse and resource utilization. Most of the published reports, here again, confirm the significant contribution of attitudes towards treatment and their impact on adherence and clinical outcomes. Negative critical attitudes can be enduring and may require specific targeted behavioural interventions in addition to optimization of medication-based treatment. Systematic reviews and a meta-analysis of various approaches to enhance compliance with medication in schizophrenia have yielded inconsistent results, reflecting the many shortcomings of the studies included in the review and the meta-analysis. Most of the interventions tend to be rather complex and resource-intensive. One of the consistent findings has been the lack of impact of approaches based on psycho-education alone, without additional behavioural, family and economic support. Not only does the content of any compliance intervention approach seem to be important, but the time-course of outcome evaluation is also relevant. The need for “booster therapy” seems to be important for maintaining some of the beneficial effects of adherence-improvement therapies. Although second-generation anti-psychotics are subjectively better tolerated than first-generation anti-psychotics, their impact on compliance behaviour and improved attitudes towards treatment has not yet been systematically demonstrated in well-controlled studies. Similarly, differences between individual second-generation antipsychotic medications, in terms of impact on compliance behaviour, need to be explored. Our study aims at synthesizing the most recent data concerning this issue which is still at the core of numerous debates and hardly ever tackled in French language literature. Thanks to the summary of these data and to the testimony of 380 schizophrenic patients, we shall try to have a better understanding of what happens between the patient and his/her therapists from a relationships viewpoint.     

Compliance in epilepsy. I. Concept factors and influence factors]

The aim of this paper is to introduce compliance concept and to classify technicals, biologicas, socials and mixed factors that may influence compliance. The importance of conscious attitudes in a good patient compliance is emphasized.     

Returning for follow up: attendance compliance in an Indian psychiatric clinic.

Attendance compliance was studied in first time outpatient attenders at an Indian psychiatric clinic. Compliance was positively associated with the patient's willingness to attend the initial consultation, being given an early appointment time for the first follow up appointment, good work prognosis and informing the patient's accompanying relative of this good work prognosis. Factors associated with decreased compliance were telling the patient the expected duration of treatment and an illness duration of less than six months at the time of presentation. The results have implications for timing of the subsequent appointment, developing rapport with the patient and being circumspect about what the patient is told.     

Vers une gestion autonome de la médication en psychiatrie ? Approche anthropologique

From the patient’s viewpoint, a good quality of compliance supposes a good relationship with his/her doctor; this relationship is directly linked to the heeding and the interest shown to the patient, and not to his/her symptoms alone. If individual motivation plays an important part at the outset, it will nevertheless be seriously influenced by the relationship between the doctor and his/her patient. It is one of the rare factors for which a positive correlation with compliance can be observed, as shown by practically all medical psychological research. These well-known classical medical notions meet with average values of non-compliance, which may vary widely. These data are proof of the wide gap existing between what is expected and what is actually achieved. This discrepancy is felt by the patient as well as by his/her therapist, and involves many other factors linked to culture, to the medical and religious background, to medical anthropology, and to the real or supposed proprieties of the Pharmakon. Our study aims at synthesizing the most recent data concerning this issue, which is still at the core of numerous debates and hardly ever tackled in French language literature. Based on the summary of these data and on the testimony of 135 persons involved in this dynamic (patients, families, doctors, nurses, members of pharmaceutical industry), we shall try to obtain a better understanding of what happens between the patient and his/her therapists from an anthropological viewpoint. Social isolation remains one of the greatest losses in mental disease. For many authors, people with schizophrenia can have no friends, no spouse, and sometimes no family. Two thirds of the patients with schizophrenia return to their parents’ house when discharged from a hospital after the first psychosis. Family members generally receive very little education as to what they can expect. They may not even know the importance of medication compliance. Family members are the primary victims of violence from psychotic individuals, usually their own son or daughter, and most families cannot believe their own son or daughter would be capable of such violence. Although families are usually the main care givers at the beginning of schizophrenia they often find their experience very frustrating for a number of reasons, and consequently relationships suffer. Family education and support have been shown to improve outcomes considerably and family education is the second strongest factor in relapse prevention. Without education and good relapse prevention families often disintegrate. Most of the homeless mentally ill in downtown city cores have lost their family relationships. It is not a reflection on their families so much as the lack of adequate treatment and support. The families tried again and again but finally lost their sick relative. These reflections show how information of and about the psychiatric patient is necessary, and underlines the importance of the relationships between the patient and his family. Our article also insists on this theme which is rarely developed in the literature.     

The role of the practice nurse in the management of depression

The feasibility of providing practice nurse support as an adjunct to standard general practitioner treatment to patients with depressive disorders prescribed antidepressant medication has been demonstrated in clinical practice and in pilot work.

The main functions for practice nurses treating patients with depressive disorders include: assessment of depression; monitoring clinical progress; enhancing treatment compliance; promoting social change and education of the patient and carers.

Practice nurse support for people with depressive disorders should be based on clear clinical accountability in relation to GPs and other members of primary care and mental health care teams, suitable training programmes for practice nurses, and further research designed to establish the most cost-effective uses of such an innovation.     

Compliance with psychiatric referrals from a general hospital psychiatry outpatient clinic

This study examines the referral patterns of 949 patients seen in a general hospital psychiatry outpatient clinic during a 15-month period. One hundred patients referred to outpatient psychotherapists were interviewed by telephone to determine compliance rates with referral recommendations. Forty-five percent reported compliance with the referral, defined as attendance at one or more psychiatric follow-up visits. Factors associated with higher compliance rates were being married, being referred at the initiation of the therapist and not the patient, and, for a subgroup of patients, receiving a list of potential psychotherapists. Neither diagnosis nor severity of illness predicted compliance, and self-referral was not associated with improved compliance. There was also no relationship found between satisfaction with the referral procedure and subsequent compliance with the referral. In 49% of the noncompliant cases, reasons cited were a self-perceived lack of need for continuing treatment due to symptom resolution and insufficient motivation.     

Psychological conditions of patient's decision to break off the treatment with atypical neuroleptic: a case study

Patient's compliance is an important factor in treatment of schizophrenia. As a part of a wide field of compliance problems, subjective experiences of neuroleptic therapy are important for adherence to treatment. Not only pharmacological action of the given drug but also the patient's subjective and psychological experiences of this action and his/her interpretations of what he/she feels are crucial for the successful treatment of schizophrenia. The change in patient's mental state is followed by changes in patient's intrapsychic attitudes, thoughts and emotions, in his/her relationship with the important persons in environment and with the global social milieu as well. In this paper the case of a psychotic patient was described. The patient responded well to low doses of risperidone but then refused to continue the treatment. Her refusal can be understood in terms of her inability to face developmental tasks (separation process) and interpreted in psychodynamic manner. It is also clear that it has transferential meaning. In conclusions the '"awakening" problem' is described. In some cases after treatment with atypical neuroleptics good clinical improvement can be seen. Sometimes it is coined as "awakening". Many "awakened" patients experience novel set of challenges after reduction in psychotic symptoms. If it is too difficult for them to try to solve these problems, like it was in the case described above, they can drop out the treatment.     

Evaluating treatment effectiveness

When deciding which treatments are of benefit, results from placebo-controlled trials are conventionally preferred above all others, and treatments not supported by such trials are viewed sceptically. In this paper it is argued that while randomised controlled trials are desirable they are not always informative. Other, less robust, research designs can be acceptable when they provide independent evidence that their results are not invalidated by remission, regression to the mean, or placebo effect, particularly if they provide post-treatment follow-up assessments. Even when there are difficulties with a research design one can reasonably conclude that the treatment was responsible for the improvement provided a standard treatment was delivered, patient compliance was good, and a dose-response relationship was identified.     

The relationship between homework compliance and treatment outcomes among older adult outpatients with mild-to-moderate depression.

OBJECTIVE: The authors extend previous research on homework in psychotherapy by examining the relationship between homework compliance and therapeutic outcome among depressed older adult outpatients (N = 63), addressing previous limitations by using session-by-session therapist ratings of homework compliance and including both interviewer ratings and patient self-reports of outcomes. METHODS: Patients were participants in a randomized clinical trial evaluating the efficacy of desipramine versus cognitive/behavioral therapy-alone (C/B-Alone) versus a combination of the two (Combined). Given the current study's focus on homework compliance, only patients assigned to conditions with assigned homework in the clinical trial (i.e., C/B-Alone and Combined conditions) were included. RESULTS: Results of hierarchical regression analyses indicated that homework compliance contributed significantly to posttreatment outcome as measured by both interviewer-administered and patient self-report measures of depression. A separate series of ANOVAs also found significant differences in pre-posttreatment change between patients scoring above and below the median of reported homework compliance. Findings were similar for patients in the C/B-Alone and Combined conditions. CONCLUSION: The study's results call for additional research on issues related to homework compliance with older adult patients.     

Determinants of nasal CPAP compliance

BACKGROUND: Obstructive sleep apnea is a prevalent condition with potentially serious medical and psychosocial consequences. Nasal continuous positive airway pressure (CPAP) is the treatment-of-choice and has been shown to reduce the frequency of nocturnal respiratory events, improve sleep architecture and decrease daytime sleepiness. Patient compliance with CPAP is disappointingly low. Previous studies examining determinants of CPAP compliance have limited the variables studied to patient (sociodemographic), disease status, and treatment variables, with few reliable determinants found. METHODS: The purpose of the current study was to investigate the relationship between objectively measured CPAP compliance and variables from social cognitive theory (SCT) and the transtheoretical model (TM). Scales that measure variables from each model were developed and reliability evaluated. The relationship between the SCT and TM variables and compliance at 1-month post-CPAP-fitting was prospectively evaluated on 51 first-time CPAP users. SCT and TM variables were measured on the day of CPAP-fitting, at 1-week post-CPAP-fitting, and at 1-month post-CPAP-fitting. RESULTS: SCT variables measured 1-week post-CPAP-fitting (R(2)=0.261, P=0.001) and TM variables measured 1-week post-CPAP-fitting (R(2)=0.17, P=0.002) accounted for a statistically significant amount of variance in objective CPAP compliance measured at 1 month. The decisional balance index (from TM) individually accounted for a significant amount of variance in objective CPAP compliance in the above analyses. CONCLUSIONS: The ability of these new behavior change scales to predict CPAP compliance provides us with a new direction of research to better understand factors associated with compliance. The principal advantage of these theory-driven and empirically validated scales are that they measure modifiable factors that can provide the basis for sound interventions to improve CPAP compliance.     

Shared decision making and medication management in the recovery process

Mental health professionals commonly conceptualize medication management for people with severe mental illness in terms of strategies to increase compliance or adherence. The authors argue that compliance is an inadequate construct because it fails to capture the dynamic complexity of autonomous clients who must navigate decisional conflicts in learning to manage disorders over the course of years or decades. Compliance is rooted in medical paternalism and is at odds with principles of person-centered care and evidence-based medicine. Using medication is an active process that involves complex decision making and a chance to work through decisional conflicts. It requires a partnership between two experts: the client and the practitioner. Shared decision making provides a model for them to assess a treatment's advantages and disadvantages within the context of recovering a life after a diagnosis of a major mental disorder.     

Reduction of side effects by combining clozapine with amisulpride: case report and short review of clozapine-induced hypersalivation-a case report

Side effects from a high-dose clozapine treatment for a schizophrenic patient led to massive compliance problems. The dose of clozapine could be halved without recurrence of an acute psychotic symptomatology by concomitantly administering amisulpride. The side effects, especially hypersalivation, disappeared almost entirely, which in turn led to good compliance. In a short review we would like to present the pathophysiology and therapeutic options of clozapine-induced hypersalivation.     

COMPLIANCE WITH OUTPATIENT LITHIUM THERAPY

This study was conducted to identify factors that influence compliance in patients being treated with lithium carbonate and regularly scheduled supportive clinic appointments for major affective disorders. The researcher examined the predictive value of elements of the Health Belief Model relative to patient compliance, the demographic characteristics of patients, and the effects of patient mood and type of treatment on patient compliance. Patient compliance was operationally defined as serum lithium level within a recommended therapeutic range and attendance at 75 percent or more of regularly scheduled clinic appointments for six months prior to the study. Fifty patients (67%) were compliant with both indices specified by the research, and only three patients (4%) were noncompliant with both indices. Lithium compliance was significantly greater among married patients and patients with higher levels of education. Appointment-keeping compliance was positively associated with individual therapy and increased patients' perceptions of continuity, and negatively correlated with patients' perceptions of increased costs of treatment. The study demonstrates the complexity of the issue of patient compliance with the long-term treatment of primary affective disorders and supports the need for additional research. While some findings suggest interventions to improve patient adherence, scrutiny and testing of these strategies to promote compliance is necessary to determine their effectiveness.     

Compliance and coping potential of cancer patients treated in liaison-consultation psychiatry

OBJECTIVE: To investigate the impact of psychiatric illness, aggression, and other covarying variables on the compliance and coping potential of cancer patients treated in liaison-consultation psychiatry. METHODS: The study involves 270 cancer patients who were admitted to the oncology ward for diagnosis and treatment. Each patient took part in a psychiatric consultation. We used the Transplant Evaluation Rating Scale (TERS), which provides a system for differentially recording the patient's compliance and coping potential (total score for the TERS items 3-10). Following standardization using the basic psychooncological documentation (PO-BADO), the demographic variables were recorded. We also identified the internal processes which each patient used to deal with the disease using criteria established by Kübler-Ross as well as the phases of cancer experience according to Fawzy. RESULTS: Twenty-three variables were checked for their relationship to the coping and compliance potential. For 13 of these, the Mann-Whitney U-test or Spearmann-Rank correlation calculated exceeded the required Bonferroni-adjusted significance level. The calculation of an ordinal regression model containing these significant single variables showed that the following variables are associated with a lower compliance and coping potential according to their estimate (Beta-value): aggression as the dominant form of dealing internally with cancer (Kübler-Ross), pre-existing DSM IV Axis 1 psychiatric disorders, carcinoma-induced psychiatric disorders, necessity of treatment with neuroleptics and male gender. Acceptance as the dominant form of dealing internally with cancer (Kübler-Ross) is strongly associated with a higher compliance and coping potential. CONCLUSION: The results show that the compliance and coping potential of oncological in-patients can be comprehensively described by the Transplant Evaluation Rating Scale. The instruments of measurement used in the study are also useful for describing risk factors associated with low levels of compliance and coping potential.     

Does attachment theory offer new resources to the treatment of schizoaffective patients?

This paper focused on considering schizoaffective disorder in the light of Attachment Theory: a case of intensive psychotherapy with a patient with a schizoaffective disorder was presented. In this case, Attachment Theory provided a useful framework for understanding the patient as well for her treatment. The core of the treatment was to build a strong therapeutic alliance in which compliance with medication and elaboration of psychological processes could be achieved. This paper could contribute to opening the discussion about the relationship between schizoaffective disorder and Attachment Theory.     

Hydrodynamic principles in hydrocephalus: the engineer's perspective

There have been significant improvements in the prognosis for patients suffering from hydrocephalus stemming from the introduction of the cerebrospinal fluid (CSF) shunt some 40 years ago. Currently, one of the major obstacles to effective shunt treatment is the mismatch between the physiology of the patient and the hydraulics of the shunt system. In order to maintain the proper relationship between CSF and cerebrovascular pressures, the implanted shunt needs to establish normal CSF outflow (absorption) and storage (compliance). Many of today's shunts establish a limited range of normal CSF outflow (absorption) and storage (compliance) once implanted, but a mismatch between CSF and cerebrovascular pressures may exist when the patient changes body position during daily activities. An uncoupling of these pressures creates mechanical strains within cerebral tissues, which are implicated in pathologies related to shunt malfunction. We suggest that re-establishment of normal CSF outflow resistance, which by definition is an indicator of both absorption and compliance, is a fundamental requirement for shunt treatment under most conditions.     

Schizophrenic patients' subjective reasons for compliance and noncompliance with neuroleptic treatment

Although several factors influencing schizophrenic patients' compliance with neuroleptic treatment have been investigated, the subjective reasons that patients are willing or reluctant to take medication have rarely been examined. In a follow-up study of a sample of schizophrenic patients currently undergoing psychiatric treatment in the city of Leipzig, 307 patients were asked about their subjective reasons for medication compliance or noncompliance by administering the Rating of Medication Influences (ROMI) Scale. The perceived benefit from medication proved to be the main reason for patients' compliance with neuroleptic treatment. Respectively, patient-reported noncompliance was mainly explained by negative side effects of medication. However, there were no statistically significant differences in responses between the patients receiving conventional versus second-generation antipsychotics. A positive relationship with the therapist and a positive attitude of significant others toward neuroleptic treatment contributed to patients' medication compliance. Reasons for noncompliance with neuroleptic treatment were lack of acceptance of the necessity of pharmacological treatment and lack of insight into the disease. The results emphasize the importance of psychoeducation in enhancing patient compliance with neuroleptic treatment.