Between compliance and freedom: the patient's statement

According to the patient, obtaining a good compliance is related to a good relationship with his practitioner; this relationship is directly connected to being a good listener for the patient, and not only for their symptoms. If the individual motivation is very important at the beginning, it will be itself greatly influenced by the relationship between the practitioner and the patient. It is one of the rare factors with a positive correlation with compliance, that's what almost all of the researches on medical psychology have observed. Once the problem is sumed up, it's the turn to speak for the patient, who explains how he considers compliance.     

Evaluating mental health services in a Greek community

This study aims to evaluate rendered mental health services for children and adolescents through the investigation of those factors which are related to non-compliance with therapy and which affect treatment outcome. Data were collected from the files of all new cases who applied to a Community Mental Health Centre in Athens during 2000–2002 (N = 363). For each case, the following factors were examined: age, sex, family situation, parents’ educational level, referral source, child’s psychiatric and psychosocial diagnoses, type of proposed therapy, phase at which termination of therapy occurred and outcome. Around 45.7% of the sample did not complete therapy. The probability of treatment compliance increased when the patient was male, with a diagnosis of a specific developmental disorder, treated in a well-structured therapy programme, was from a healthy family environment and his mother was better educated. On the contrary, an adverse family situation (one-parent family, inadequate parental supervision) and the female sex had a negative association with treatment compliance. Most of the cases discontinued their treatment upon completion of the diagnostic procedure. Referral source did not influence treatment compliance. Evaluation of our service has shown that more attention should be paid to less-educated families and those in adverse situations, particularly when the patient is female.     

Clinical neurology of insomnia in neurodegenerative and other disorders of neurological function

Complaints of insomnia are prevalent in neurodegenerative and neurological disorders. Neurologists therefore must be aware of the underlying causes, pathophysiologic mechanisms, and potential interventions when encountering a patient with underlying neurological disorders who is also complaining of poor sleep and insomnia. This article describes the underlying pathophysiology, diagnostic approaches, and potential interventions for insomnia in the neurological patient. Clinicians need to recognize that insomnia in older patients with underlying neurological disorders is not only unique, but also complex, demanding comprehensive and careful evaluation and management. Treatment of insomnia should start by addressing nonpharmacologic options, including improvements in sleep hygiene, improving sunlight exposure during the day, and searching for underlying reversible causes, such as sleep apnea, restless legs syndrome, periodic leg movements, and circadian rhythm disturbances, all of which can precipitate insomnia when left untreated. Some patients may benefit from targeted and carefully tailored pharmacologic treatment. Successful amelioration of insomnia can ultimately be a very rewarding experience for the patient, family members, and the practitioner.     

The importance of psychosocial interventions and patient involvement in the treatment of schizophrenia

The multifactorial nature of schizophrenia and the wide-ranging impact of the illness on the patient, their family, carers and healthcare providers mean that clinicians must be prepared to take a holistic approach to treatment. It is widely recognized that a patient's beliefs about their treatment and their experiences of schizophrenia can be very important in determining both attitude towards treatment compliance and behaviour in response to symptoms of the illness and environmental stress. Antipsychotic therapy remains the cornerstone of treatment for schizophrenia. However, there is now growing evidence to support the benefits of non-pharmacological interventions, when used in combination with antipsychotic treatment, in relieving symptoms, improving occupational and social functioning and reducing the risk of relapse. In particular, these interventions appear to provide benefits in coping skills and social and vocational functioning, as reflected in a greater ability to function independently and an improvement in quality of life. Systematic assessment of non-pharmacological therapies in schizophrenia is still a relatively new science, but there is good evidence that psychosocial therapies, such as family intervention therapy, cognitive-behaviour therapy and compliance therapy can markedly change a patient's behaviour and improve adherence to treatment and hence interaction with families, carers and healthcare providers. Psychosocial interventions can be implemented from the first episode of psychosis onwards and can contribute to an improved overall outcome in schizophrenia, to patients being more satisfied with their treatment, and to a better quality of life for the patient and their family. Initial comprehensive assessment will involve regular contact with the patient and opens channels for an ongoing dialogue. It is important that these discussions with the patients and their families and carers not only cover the need for social, emotional and behavioural support but include regular discussion of the acceptability and side-effects of antipsychotic treatment so that problems can be identified and addressed promptly. While the importance of non-pharmacological interventions in improving the quality of patient care is becoming widely accepted, access to psychological, psycho-educational and family support is by no means universal in current clinical practice. It is important that these services, provided by appropriately trained personnel, are made available to all patients for whom they may be appropriate.     

Family factors and the course of bipolar affective disorder

Measures of family attitudes (expressed emotion [EE]) and interactional behaviors (affective style [AS]), both of which have been found to predict relapse in schizophrenia, were obtained from key relatives of 23 hospitalized recently manic bipolar patients. Patients were then followed up for a period of nine months after hospital discharge and rated on measures of clinical course, social adjustment, and medication compliance. Levels of intrafamilial EE and AS were found to predict likelihood of patient relapse at follow-up, especially when used as conjoint predictors of patient outcome status. Levels of AS also predicted degree of social adjustment at follow-up. The predictive relationships observed were independent of patient medication compliance, treatment regimen, baseline symptoms, demographics, and illness history. Results suggest that the emotional atmosphere of the family during the postdischarge period may be an important predictor of the clinical course of bipolar disorder.     

Peer review committees and state licensing boards: responding to allegations of physician misconduct

Although physicians tend to be more concerned about malpractice actions, adjudication of complaints of alleged physician misconduct by peer review organizations and state licensing authorities can have equally serious consequences. Unlike medical malpractice, no patient injury is necessary to support the claim of alleged misconduct. Unlike malpractice, in which a plaintiff must be the injured party, in administrative peer review, colleagues, family members, and patients may all qualify as potential complainants. Unlike malpractice, where the standard of care is what the average prudent practitioner would be expected to do in similar circumstances, in peer review, the standard of care is the code that the organization has endorsed and to which the individual practitioner has agreed by choosing to join the organization. Forensic psychiatrists who may serve either as experts for a peer review or state board investigation or as peer review committee members must understand the legal foundation of the process and the attendant psychological and sociopolitical forces affecting the different parties.     

Predictors of noncompliance in patients with schizophrenia

BACKGROUND: Around 50% of patients with schizophrenia do not fully comply with treatment, and noncompliance is linked to relapse, rehospitalization, poor outcome, and high economic costs. The health belief model views noncompliance as a decision made by the patient, arrived at after weighing the perceived risks and benefits of treatment. DATA SOURCES: A MEDLINE search for the years 1980-2002 using combinations of the keywords schizophrenia, compliance, adherence, antipsychotics, tolerability, and side effects was used to identify articles investigating the factors influencing compliance in schizophrenia. RESULTS: Many factors influence compliance, including those that affect patients' beliefs about their illness and the benefits of treatment (e.g., insight into illness, belief that medication can ameliorate symptoms), perceived costs of treatment (e.g., medication side effects), and barriers to treatment (e.g., ease of access to treatment, degree of family or social support). Medication side effects that are distressing to patients and linked to noncompliance include extrapyramidal side effects, neuroleptic dysphoria, akathisia, sexual dysfunction, and weight gain. Compliance can be improved by cognitive-behavioral therapies, such as compliance therapy, and other psychosocial interventions associated with improved social functioning and a lower risk of rehospitalization. Treatment adherence may also be improved by use of atypical antipsychotics with few perceived side effects. CONCLUSION: By considering the factors leading to noncompliance and adopting a comprehensive strategy for improving compliance, encompassing psychosocial intervention and optimum choice of medication, the management of schizophrenia could be greatly improved.     

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.     

Therapeutic use of auto-CPAP

Auto-CPAP is a new technology by which a continuous positive airway pressure (CPAP) device automatically adjusts the level of mask pressure to the patient's requirements. It has been proposed with two different goals: (1) to improve treatment and (2) to perform automatic titration. The improvement of treatment involves two aspects: (a) improving treatment efficacy and (b) improving compliance with treatment. The rationale behind better treatment efficacy is that the patients' requirements vary over both the short and long term. However, there are few data in the literature showing that this is true, let alone concerning its importance and impact. Published studies fail to demonstrate better treatment efficacy with auto-CPAP compared with manually titrated conventional CPAP. The rationale behind improved compliance with treatment is that auto-CPAP should achieve the same treatment efficacy with lower nasal pressures, and thus reduce side effects and improve compliance. Again, the postulate that higher nasal pressures cause lower compliance is not supported. Published studies show variable results both on the level of pressure delivered with an auto-CPAP device (as compared with the optimal pressure used with conventional fixed pressure, but this probably depends on the definition of optimal fixed pressure) and on observed compliance with auto-CPAP. The main problem here is that most studies were not double-blinded which is critical as the end-point (i.e., patient compliance), heavily depends on the relationship between the medical staff and the patient. The aim of titration with auto-CPAP is to save on costs, as patients are treated with fixed conventional CPAP once the titration procedure is accomplished. Auto-titration can be performed either in the sleep laboratory (then the auto-titrating devices can be sophisticated and cumbersome) or in the patients' home. Published studies suggest that auto-titration can be accurately performed, but given the additional cost of the device, the necessity of supervision (albeit a less qualified supervision than with manual titration) and the failure rate, the cost-effectiveness of auto-titration remains to be established.     

Urodynamic studies in spinal cord tethering

Introduction

Tethered cord syndrome (TCS) is of particular interest to urologists through its effects on the function of the lower urinary tract. Tethering of the spinal cord can result in bladder dysfunction with multiple manifestations, clinically raging from urinary retention and detrusor under-activity to urinary incontinence, over-activity of the detrusor, and sphincter dysfunction. Goals of management include protecting renal function and preserving patient quality of life.

Methods

Evaluation of a TCS patient with urinary complaints begins with a thorough history and physical examination. Further characterization of urinary symptoms with a voiding diary provides vital information that helps to direct treatment while engaging the patient and family in the treatment plan. Urodynamic studies then provide key diagnostic data regarding bladder function, bladder outlet resistance, and urinary sphincter function. In the pediatric population, particular care must be paid to counseling patients and their families prior to the procedure to alleviate the often-considerable anxiety associated with an invasive procedure.

Conclusion

The armamentarium for management of neurogenic bladder associated with TCS includes behavioral training, biofeedback therapy, medications, patient-performed procedures, and surgical intervention. The choice of intervention depends on the patient’s symptoms, urodynamic findings, and patient and family preferences. The primary problem of TCS should be addressed first through detethering, and then the urological team can use progressively more aggressive therapies as necessary. Interpretation and treatment by a dedicated, specialized, multidisciplinary team that includes the pediatric urologist, pediatric neurosurgeon and dedicated nurse practitioner, is critical for successful treatment.     

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.     

Treatment of culturally diverse children and adolescents with depression

This article is written for the practitioners treating depression in ethnic minority youth. It will review the context in which services are delivered to these youth: Researchers have recognized persistent ethnic differences in terms of utilization of services and unmet need. Furthermore, when ethnic minority youth do receive pediatric mental health care, the services that they receive may differ from those given to White patients. The reasons for these discrepancies have been examined in numerous studies, and have included contextual variables (economics, availability, and accessibility of services), patient variables (differences in prevalence or manifestation of the disorder, cultural beliefs and attitudes, preferential use of alternative or informal services, health literacy, and adherence), and provider variables (referral bias and patient-provider communication). Information about the differences between White and minority youth in the pharmacodynamics and pharmacokinetics of the antidepressant response is still limited. There are significant challenges for developing evidence-based guidelines that inform practice with these youth, hinging on both the underrepresentation of ethnic minority groups in clinical trials, and the great variability in biological and cultural characteristics of individuals in ethnic minority categories. Awareness on the part of the practitioner of the cultural variables that influence help-seeking and ongoing utilization of mental health services may aid in the engagement, effective treatment, and retention of ethnic minority children and adolescents with depression. However, given the great heterogeneity that exists within any cultural grouping, clinicians will need to integrate information about cultural patterns with that obtained from the individual patient and family to inform optimal practices for each patient. This article is written to enhance awareness on the part of the practitioner as to the variables that influence psychiatric care for depression in culturally diverse youth. The mental health needs of minority youth are not well served: They are treated less frequently, and when they are treated, the services they receive are less frequently adequate. The reasons that have been proposed for the disparities in their care, particularly with regard to diagnosis and treatment for depression, will be reviewed. They include contextual factors (such as economics, insurance, and other variables affecting the availability of services) patient and family factors (such as prevalence, symptom presentation, and values and beliefs that influence whether patients are referred to and avail themselves of services), and provider factors (such as referral bias and patient-provider communication, which affect whether patients engage and stay in treatment). The implications for the practitioner treating ethnic minority youth with depression will be discussed. Culture, as used in this article, refers to the common values, beliefs, and social behaviors of individuals with a shared heritage. Some aspects of culture that are likely to influence service utilization include health beliefs, particularly regarding models of mental illness, and level of stigma toward mental health treatment, which are frequently shared by individuals in a cultural group. However, some caveats for the explanatory potential of "culture" should be kept in mind. Conventions for naming groups vary between investigators and over time (e.g., the restriction of the category "White" into "White NonHispanic," is quite recent). Although heterogeneity is assumed within a named cultural or racial group, the terms Hispanic, Asian, and African-American incorporate subgroups can be very different in linguistic, historical, and geographical ancestry (e.g., Stewart 2008 ), and each group incorporates individuals who may not share any components of their historical heritage. Even among those with historical ties, values, beliefs, and social behaviors can vary according to the extent to which they identify with the mainstream culture. Social class frequently creates a "culture" of its own, with individuals in the same social class across traditional cultural groupings sharing disparities in care, and many beliefs and values. Individuals are likely to belong to numerous "cultures," and may not share specific typical behaviors or beliefs with any of them.     

From quality assurance to quality improvement

As we are learning to master the methods of quality assurance, a new conceptual approach focused on quality improvement is being advocated. But this new approach is not a derailment for health care practitioners committed to improve patient care quality. Rather, it is a progressive step that builds upon the concepts and methods of quality assurance. Whereas quality assurance tends to focus on correcting problems in patient care quality--especially individual practitioners' problems--quality improvement focuses on finding opportunities to improve quality by changing systems as well as individual practitioner behavior. Whereas quality assurance tends to rely primarily on standards or guidelines for the structures and processes of care and the intensive review of individual cases with undesirable outcomes, quality improvement also utilizes statistical profiles of outcomes, structures, and processes as baselines against which improvement can be measured. Whereas quality assurance may engender defensiveness in an individual practitioner, quality improvement is based on the health care practitioner's professional ethic and pride in providing even better care to patients tomorrow than is possible today. To improve patient care quality, it is necessary to examine the structures, processes, and outcomes of care. The structures and processes can be controlled by the practitioner and organization; the outcomes are the benchmarks against which the effectiveness of the structures and processes can be evaluated. Outcomes in health care are the effects of more than just the structures and processes controlled by the practitioner and organization. Therefore, outcomes are not direct and complete measures of the quality of the care provided. They are instead indicators of performance. These indicators can focus attention on care that lies outside the normal statistical parameters of performance and can provide baselines against which improvements can be measured. The monitoring and evaluation process described in Joint Commission standards is a method for establishing priorities and using indicators to improve the quality of patient care. This method can be used to focus case-based review of care and to establish baselines for continuous improvement. This conceptual approach that emphasizes quality improvement and the use of the monitoring and evaluation process is guiding the Joint Commission's development of clinical indicators and revision of its standards and survey process to help health care organizations in the transition from quality assurance to quality improvement.     

Targeting behavioral therapies to enhance naltrexone treatment of opioid dependence: efficacy of contingency management and significant other involvement

BACKGROUND: Contingency management (CM) and significant other involvement (SO) were evaluated as strategies to enhance treatment retention, medication compliance, and outcome for naltrexone treatment of opioid dependence. METHODS: One hundred twenty-seven recently detoxified opioid-dependent individuals were randomly assigned to 1 of 3 conditions delivered for 12 weeks: (1) standard naltrexone treatment, given 3 times a week; (2) naltrexone treatment plus contingency management (CM), with delivery of vouchers contingent on naltrexone compliance and drug-free urine specimens; or (3) naltrexone treatment, CM, plus significant other involvement (SO), where a family member was invited to participate in up to 6 family counseling sessions. Principal outcomes were retention in treatment, compliance with naltrexone therapy, and number of drug-free urine specimens. RESULTS: First, CM was associated with significant improvements in treatment retention (7.4 vs 5.6 weeks; P =.05) and in reduction in opioid use (19 vs 14 opioid-free urine specimens; P =.04) compared with standard naltrexone treatment. Second, assignment to SO did not significantly improve retention, compliance, or substance abuse outcomes compared with CM. Significant effects for the SO condition over CM on retention, compliance, and drug use outcomes were seen only for the subgroup who attended at least 1 family counseling session. The SO condition was associated with significant (P =.02) improvements in family functioning. CONCLUSION: Behavioral therapies, such as CM, can be targeted to address weaknesses of specific pharmacotherapies, such as noncompliance, and thus can play a substantial role in broadening the utility of available pharmacotherapies.     

Drug compliance of children and adolescents with epilepsy.

BACKGROUND: Compliance behavior depends on the specific clinical situation, the nature of the illness, and the treatment program. The aim of this study was to determine the rate of drug compliance in families caring for a child or adolescent with epilepsy and to describe some associated factors. METHODS: All the patients with epilepsy under 18 years of age who were attending the Motahary Clinic of Shiraz for a six-month period and their families were interviewed. RESULTS: The total number of participants was 181 patients. Drug compliance was satisfactory in 72.4% of the patients. Etiology of epilepsy, mono-therapy versus poly-therapy, duration of the disease, age of the patient, accompanying disease, parental smoking, parental education and living in urban versus rural areas did not significantly influence the drug compliance but maternal age was significantly higher in patients with poor compliance. Also, patients with positive family history of epilepsy had more noncompliance. Moreover, family size had a significant effect on drug compliance. Finally, patients using phenobarbital were more complaint than other patients. CONCLUSIONS: In this study, drug compliance was satisfactory in almost three-fourths of the patients with epilepsy. There was no significant association between noncompliance and the cause of epilepsy, duration of the disease, socio-economic status (parental smoking, living place, education) and number of drugs used to treat the illness. But paying attention to medication education for patients and parents, decreasing the complexity of the treatment regimen and younger possibly more motivated mothers in a small family, increased the drug compliance.     

脑梗死病人社会支持及家庭功能对治疗依从性的影响

目的探讨脑梗死病人社会支持及家庭功能对治疗依从性的影响。方法选取2013年1月至2015年1月收治的脑梗死病人116例,采用Morisky服药依从性量表-8(MMAS-8)评估病人的治疗依从性,采用社会支持评定量表(SSRS)评估病人的社会支持情况,采用APGAR家庭功能评估表评估病人的家庭功能情况。采用多元线性回归分析评价社会支持及家庭功能对脑梗死病人治疗依从性的影响。结果所有病人均能完成调查,MMAS-8评分(7.1±1.0)分,其中依从性良好56例(48.3%),依从性一般32例(27.6%),依从性差28例(24.1%);多元线性回归分析结果显示,家庭人均月收入、病程、主观支持、情感度、亲密度、合作度是影响病人治疗依从性的重要因素。结论脑梗死病人的治疗依从性与社会支持度和家庭功能状况息息相关,护理人员应当做好相关干预,提高病人的家庭、社会支持度,改善病人治疗依从性,进而改善病人预后和生活质量。     

住院精神分裂症患者主观舒适度的影响因素分析

目的 了解影响精神分裂症患者主观舒适度的相关因素。方法 对200例住院精神分裂症患者测评“抗精神病药物治疗中主观舒适度（SWN）简表”及自制的“相关因素调查表”。结果 住院精神分裂症患者SWN评分异常率为31％，SWN评分异常组与正常组相比，在总病程、住院次数、服药次数、药物剂量、家庭经济水平、服药依从性、社会支持、医患关系、诊断亚型、合并使用抗副作用药、藏药行为等方面差异显著。2项Logistic回归分析显示，精神分裂症患者主观舒适度影响因素依次为：药物剂量、合并使用抗副作用药、服药依从性、藏药行为、家庭经济水平、医患关系。结论 在治疗精神分裂症患者时应注意多因素对主观舒适度的影响，尤其注意发挥人为干预因素作用。     

Cognitive-behavioural treatment of panic disorder during pregnancy and lactation.

The treatment of panic disorder during pregnancy and lactation poses special problems. It is important that both the practitioner and patient consider a number of issues to find the most appropriate treatment for the patient. New cognitive-behavioural treatment options often circumvent the problems of pharmacotherapy for pregnant or lactating women while providing therapeutic benefits which are at least equivalent.     

The Psychiatric Family Nurse Practitioner: A Collaborator in Family Practice

The potential of the psychiatric family nurse practitioner (Psych.F.N.P.) to contribute to family practice through physical care and mental health care exists in the here and now. This role is a synthesis of 2 advanced practice roles, the psychiatric clinical nurse specialist (Psych.C.N.S.) and family nurse practitioner (F.N.P.), both of which continue to have great utility independently. This synthesis is a practical application of concepts that have evolved to meet the changing patterns of health care delivery. At this time, dual certification as a Psych.C.N.S. and F.N.P. best reflects the broad practice expertise of the psychiatric family nurse practitioner. The experienced psychiatric family nurse practitioner provides direct care for both physical and psychological needs of patients in a family practice setting.     

The BRENDA model: integrating psychosocial treatment and pharmacotherapy for the treatment of alcohol use disorders

While the U.S. Food and Drug Administration has approved several medications for the treatment of alcohol-related problems, their use has not gained wide acceptance in the United States. Typically, patients with alcohol use disorders are only referred to psychosocial support (e.g., Alcoholics Anonymous). However, the use of pharmacotherapy may complement psychosocial treatments, as evidence shows that pharmacotherapy can improve treatment outcomes. The effectiveness of pharmacotherapy depends on patient compliance with taking the medication and the context in which the medication is administered. BRENDA is a psychosocial program designed specifically to be used by many types of healthcare providers, including primary care clinicians. Designed to enhance medication and treatment compliance, BRENDA is an ideal approach for use in conjunction with pharmacotherapy. The BRENDA approach has 6 components: 1) a biopsychosocial evaluation; 2) a report of findings from the evaluation given to the patient; 3) empathy; 4) addressing patient needs; 5) providing direct advice; and 6) assessing patient reaction to advice and adjusting the treatment plan as needed. This paper describes these components and discusses how the empirical support for each component is linked to the enhancement of medication compliance and the improvement of treatment outcomes.