The Psychosocial Context Impacts Medication Adherence After Acute Coronary Syndrome

Background

Depression is associated with poor adherence to medications and worse prognosis in patients with acute coronary syndrome (ACS).

Purpose

To determine whether cognitive, behavioral, and/or psychosocial vulnerabilities for depression explain the association between depression and medication adherence among ACS patients.

Methods

One hundred sixty-nine ACS patients who agreed to have their aspirin adherence measured using an electronic pill bottle for 3 months were enrolled within 1 week of hospitalization. Linear regression was used to determine whether depression vulnerabilities predicted aspirin adherence after adjustment for depressive symptoms, demographics, and comorbidity.

Results

Of the depression vulnerabilities, only role transitions (beta?=??3.32; P?=?0.02) and interpersonal conflict (beta -3.78; P?=?0.03) predicted poor adherence. Depression vulnerabilities did not mediate the association between depressive symptoms and medication adherence.

Conclusions

Key elements of the psychosocial context preceding the ACS including major role transitions and conflict with close contacts place ACS patients at increased risk for poor medication adherence independent of depressive symptoms.     

The Influence of Informal Caregivers on Adherence in COPD Patients

Background

Contributions of informal caregivers to adherence among chronic obstructive pulmonary disease (COPD) patients remain understudied.

Purpose

This study aims to evaluate the association between caregiver presence and adherence to medical recommendations among COPD patients.

Methods

Three hundred and seventy-four COPD patients were asked whether they had a caregiver. Medication adherence was assessed using pharmacy refill data. Smoking status was based on patient self-report. One-way ANOVAs and chi-square analyses were performed controlling for age and number of illnesses.

Results

Compared with the ??no caregiver?? group, antihypertensive medications adherence was higher in the ??spousal caregiver?? (0.68 vs. 0.81; 95?% CI?=?0.04 and 0.22) and ??non-spousal caregiver?? (0.68 vs. 0.80; 95?% CI?=?0.03 and 0.22) groups; long-acting beta agonist adherence was higher in the ??spousal caregiver?? group (0.60 vs.0.80; 95?% CI?=?0.05 and 0.43). Patients in the ??spousal caregiver?? group had fewer current smokers compared with the ??no caregiver?? (?? ²?=?16.08; p?<?0.001) and ??non-spousal caregiver?? (?? ²?=?5.07; p?<?0.05) groups; those in the ??non-spousal caregiver?? group reported fewer smokers than the ??no caregiver?? group (?? ²?=?4.54; p?<?0.05).

Conclusions

Caregivers, especially spouses, may improve adherence in COPD. Future interventions may target patients without caregivers to optimize COPD management.     

Conscientiousness and Medication Adherence: A Meta-analysis

Background

Approximately a quarter to a half of all people fail to take their medication regimen as prescribed (i.e. non-adherence). Conscientiousness, from the five-factor model of personality, has been positively linked to adherence to medications in several recent studies.

Purpose

This study aimed to systematically estimate the strength and variability of this association across multiple published articles and to identify moderators of this relationship.

Method

A literature search identified 16 studies (N?=?3,476) that met the study eligibility criteria. Estimates of effect sizes (r) obtained in these studies were meta-analysed.

Results

Overall, a higher level of conscientiousness was associated with better medication adherence (r?=?0.15; 95 % CI, 0.09, 0.21). Associations were significantly stronger in younger samples (r?=?0.26, 95 % CI, 0.17, 0.34; k?=?7).

Conclusion

The small association between conscientiousness and medication adherence may have clinical significance in contexts where small differences in adherence result in clinically important effects.     

Improving Adherence to Medication in Stroke Survivors: A Pilot Randomised Controlled Trial

Background

Adherence to preventive medication is often poor, and current interventions have had limited success.

Purpose

This study was conducted to pilot a randomised controlled trial aimed at increasing adherence to preventive medication in stroke survivors using a brief, personalised intervention.

Methods

Sixty-two stroke survivors were randomly allocated to either a two-session intervention aimed at increasing adherence via (a) introducing a plan linked to environmental cues (implementation intentions) to help establish a better medication-taking routine (habit) and (b) eliciting and modifying any mistaken patient beliefs regarding medication/stroke or a control group. Primary outcome was adherence to antihypertensive medication measured objectively over 3 months using an electronic pill bottle.

Results

Fifty-eight people used the pill bottle and were analysed as allocated; 54 completed treatment. The intervention resulted in 10 % more doses taken on schedule (intervention, 97 %; control, 87 %; 95 % CI for difference (0.2, 16.2); p?=?0.048).

Conclusions

A simple, brief intervention increased medication adherence in stroke survivors, over and above any effect of increased patient contact or mere measurement. (http://controlled-trials.com, number ISRCTN38274953.)     

Are attitudes towards medication adherence associated with medication adherence behaviours among patients with psychosis? A systematic review and meta analysis

Background

Studies have shown patient attitudes to be an important predictor for health related behaviours including medication adherence. It is less clear whether patient attitudes are also associated with medication adherence among patients with psychoses.

Method

We conducted a systematic review and meta analysis of the data of studies that tested the association of attitude measures with medication adherence among patients with psychoses. 14 studies conducted between 1980 and 2010 were included.

Results

Results show a small to moderate mean weighted effect size (r ⁺ = 0.25 and 0.26 for Pearson and Spearman correlations, respectively).

Conclusions

Theory based interventions that target potentially modifiable attitude components are needed to assess the relationship between positive patient attitudes and adherence behaviours among patients with psychoses.     

Factors Associated with Discontinuation of Bupropion and Counseling Among African American Light Smokers in a Randomized Clinical Trial

Background

African Americans are at risk of inadequate adherence to smoking cessation treatment, yet little is known about what leads to treatment discontinuation.

Purpose

The purpose of this study was to examine the factors associated with discontinuation of treatment in African American light smokers (≤10 cigarettes per day).

Methods

Bupropion plasma levels and counseling attendance were measured among 540 African American light smokers in a placebo-controlled randomized trial of bupropion.

Results

By week 3, 28.0 % of subjects in the bupropion arm had discontinued bupropion, and only moderate associations were found between the plasma levels and self-reported bupropion use (r _s?=?0.38). By week 16, 36.9 % of all subjects had discontinued counseling. Males had greater odds of discontinuing medication (OR?=?2.02, 95% CI?=?1.10–3.71, p?=?0.02), and older adults had lower odds of discontinuing counseling (OR?=?0.96, 95% CI?=?0.94–0.97, p?<?0.0001).

Conclusions

Bupropion and smoking cessation counseling are underutilized even when provided within the context of a randomized trial. Future research is needed to examine strategies for improving treatment utilization among African American smokers. Trial Registration No. NCT00666978 (www.clinicaltrials.gov).     

The Necessity-Concerns Framework: a Multidimensional Theory Benefits from Multidimensional Analysis

Background

Patients’ medication-related concerns and necessity-beliefs predict adherence. Evaluation of the potentially complex interplay of these two dimensions has been limited because of methods that reduce them to a single dimension (difference scores).

Purpose

We use polynomial regression to assess the multidimensional effect of stroke-event survivors’ medication-related concerns and necessity beliefs on their adherence to stroke-prevention medication.

Methods

Survivors (n?=?600) rated their concerns, necessity beliefs, and adherence to medication. Confirmatory and exploratory polynomial regression determined the best-fitting multidimensional model.

Results

As posited by the necessity-concerns framework (NCF), the greatest and lowest adherence was reported by those necessity weak concerns and strong concerns/weak Necessity-Beliefs, respectively. However, as could not be assessed using a difference-score model, patients with ambivalent beliefs were less adherent than those exhibiting indifference.

Conclusions

Polynomial regression allows for assessment of the multidimensional nature of the NCF. Clinicians/Researchers should be aware that concerns and necessity dimensions are not polar opposites.     

Health care providers’ perspectives of medication adherence in the treatment of depression: a qualitative study

Purpose

Non-adherence to antidepressant medications is a significant barrier to the successful treatment of depression. The purpose of this study was to explore the perspectives of health care providers on antidepressant medication non-adherence in clinical practice.

Methods

Individual semi-structured interviews were conducted with a purposive sample of 31 health care providers from a range of disciplines and settings in the state of New South Wales, Australia. Interviews focused on medication adherence issues in depression and participants’ strategies in addressing them. Interviews were audio recorded, transcribed verbatim and thematically content analyzed using a constant comparison approach.

Results

Participants acknowledged medication non-adherence to be a complex problem in depression, and attributed this problem to patient, medication and environmental-specific issues. Five approaches in addressing non-adherence were reported: patient education, building partnerships with patients, pharmacological management, developing behavioural skills and building supportive networks. Challenges to the management of non-adherence were lack of time and skills, assessment of medication adherence, transition period immediately post-discharge and conflicts in views between providers.

Conclusion

Participants were able to identify issues and strategies in addressing antidepressant non-adherence; however, barriers were also identified that could impact on providers’ ability to address this issue effectively. More research is needed to develop effective multidisciplinary strategies that take into account providers’ perspectives in improving adherence to antidepressant medications.     

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.     

Does Electronic Monitoring Influence Adherence to Medication? Randomized Controlled Trial of Measurement Reactivity

Background

Electronic monitoring is recommended for accurate measurement of medication adherence but a possible limitation is that it may influence adherence.

Purpose

To test the reactive effect of electronic monitoring in a randomized controlled trial.

Methods

A total of 226 adults with type 2 diabetes and HbA1c ≥58 mmol/mol were randomized to receiving their main oral glucose lowering medication in electronic containers or standard packaging. The primary outcomes were self-reported adherence measured with the MARS (Medication Adherence Report Scale; range 5–25) and HbA_1c at 8 weeks.

Results

Non-significantly higher adherence and lower HbA_1c were observed in the electronic container group (differences in means, adjusting for baseline value: MARS, 0.4 [95 % CI ?0.1 to 0.8, p?=?0.11]; HbA_1c (mmol/mol), ?1.02 [?2.73 to 0.71, p?=?0.25]).

Conclusions

Electronic containers may lead to a small increase in adherence but this potential limitation is outweighed by their advantages. Our findings support electronic monitoring as the method of choice in research on medication adherence. (Trial registration Current Controlled Trials ISRCT N30522359)     

Long-term effects of involuntary hospitalization on medication adherence, treatment engagement and perception of coercion

Purpose

The purpose of the study was to examine the long-term influence of involuntary hospitalization on medication adherence, engagement in out-patient treatment and perceived coercion to treatment participation.

Methods

In a naturalistic observational multi-centre study, 290 voluntarily and 84 involuntarily hospitalized patients with schizophrenia or schizoaffective disorder had been followed up over a period of 2 years with half-yearly assessments. Assessments included self-rated medication adherence, externally judged medication adherence by blood levels, engagement in treatment and perceived coercion. The statistical analyses were based on multilevel hierarchical modelling of longitudinal data. Level and development of the outcome was controlled for involuntariness, for sociodemographic characteristics and clinical history.

Results

Involuntariness of the index-hospitalization did not have an effect on the development of treatment engagement or medication adherence judged by blood levels in the course of the follow-up period when the models were controlled for sociodemographic variables and clinical history. It was associated, though, with a continuously lower self-rated medication adherence. Moreover, former involuntarily hospitalized patients more often felt coerced in several treatment aspects at the follow-up assessments. Yet, there was no difference between the voluntary and involuntary group with regard to the development of the levels of adherence or coercion experiences over time.

Conclusions

Involuntary hospitalization does not seem to impair future treatment engagement in patients with schizophrenia, but formerly involuntarily hospitalized patients continue to be more sensitive to subjective or real coercion in their treatment and more vulnerable to medication non-adherence. Hereby, their risk of future involuntary hospitalization might be increased.     

Maternal flu or fever,medications use in the first trimester and the risk for neural tube defects: a hospital-based case–control study in China

Purpose

This study aims to evaluate the effects of maternal flu or fever, and medications (antibiotics and antipyretics) use in the first trimester on neural tube defects (NTDs) risk in offspring.

Methods

Data came from a hospital-based case–control study conducted between 2006 and 2008 in Shandong/Shanxi provinces including 459 mothers with NTD-affected births and 459 mothers without NTD-affected births. Logistic regression models were used to evaluate the effects of maternal flu, fever, and medications use on NTD risk. The effects were evaluated by adjusted odds ratio (OR) and 95 % confidence intervals (CIs) with SAS9.1.3.software.

Results

NTDs risks were significantly associated with maternal flu or fever (OR?=?2.63, 95 % CI?=?1.64–4.23) and antipyretics use (OR?=?3.38, 95 % CI?=?1.68–6.79), but not with antibiotics use (OR?=?1.82, 95 % CI?=?0.85–3.93). The risk effect of antipyretics use on anencephaly (OR?=?7.81, 95 % CI?=?1.96–31.13) was markedly higher than on spina bifida (OR?=?3.02, 95 % CI?=?1.08–8.42). Maternal flu or fever together with antipyretics use showed a higher OR for total NTDs (3.27 vs.1.87), anencephaly (7.38 vs.2.08), and spina bifida (2.97 vs.2.07) than maternal flu or fever with no antipyretics use.

Conclusions

Maternal flu or fever and antipyretics use in the first trimester were risk for NTDs. Maternal flu or fever together with antipyretics use increased NTD risk than only maternal flu or fever.     

Psychological Determinants of Medication Adherence in Stroke Survivors: a Systematic Review of Observational Studies

Background

Medications targeting stroke risk factors have shown good efficacy, yet adherence is suboptimal. To improve adherence, its determinants must be understood. To date, no systematic review has mapped identified determinants into the Theoretical Domains Framework (TDF) in order to establish a more complete understanding of medication adherence.

Purpose

The aim of this study was to identify psychological determinants that most influence stroke survivors’ medication adherence.

Methods

In line with the prospectively registered protocol (PROSPERO CRD42015016222), five electronic databases were searched (1953–2015). Hand searches of included full text references were undertaken. Two reviewers conducted screening, data extraction and quality assessment. Determinants were mapped into the TDF.

Results

Of 32,825 articles, 12 fulfilled selection criteria (N = 43,984 stroke survivors). Tested determinants mapped into 8/14 TDF domains. Studies were too heterogeneous for meta-analysis. Three TDF domains appeared most influential. Negative emotions (‘Emotions’ domain) such as anxiety and concerns about medications (‘Beliefs about Consequences’ domain) were associated with reduced adherence. Increased adherence was associated with better knowledge of medications (‘Knowledge’ domain) and stronger beliefs about medication necessity (‘Beliefs about Consequences’ domain). Study quality varied, often lacking information on sample size calculations.

Conclusions

This review provides foundations for evidence-based intervention design by establishing psychological determinants most influential in stroke survivors’ medication adherence. Six TDF domains do not appear to have been tested, possibly representing gaps in research design. Future research should standardise and clearly report determinant and medication adherence measurement to facilitate meta-analysis. The range of determinants explored should be broadened to enable more complete understanding of stroke survivors’ medication adherence.

     

The Effect of Patient–Provider Communication on Medication Adherence in Hypertensive Black Patients: Does Race Concordance Matter?

Background

Despite evidence of a positive effect of collaborative patient?Cprovider communication on patient outcomes, our understanding of this relationship is unclear.

Purpose

The purpose of this paper is to determine whether racial composition of the relationship modified the association between ratings of provider communication and medication adherence.

Methods

Effect modification of the communication?Cadherence association, by racial composition of the relationship, was evaluated using general linear mixed models while adjusting for selected covariates.

Results

Three hundred ninety patients were in race-concordant (black patient, black provider) relationships, while 207 were in race-discordant (black patient, white provider) relationships. The communication?Cadherence association was significantly modified in race-discordant relationships (p?=?0.04). Communication rated as more collaborative in race-discordant relationships was associated with better adherence, while communication rated as less collaborative was associated with poor adherence. There was no significant association between adherence and communication in race-concordant relationships (p?=?0.24).

Conclusions

Collaborative patient?Cprovider communication may play an influential role in black patients?? adherence behaviors when receiving care from white providers.     

Type D Personality is Unrelated to Major Adverse Cardiovascular Events in Patients with Coronary Artery Disease Treated by Intracoronary Stenting

Background

Previous research in cardiac patients suggested that type D personality, defined as a combination of negative affectivity (NA) and social inhibition (SI), was associated with adverse outcome.

Purpose

The objective of this prospective study was to examine the independent prognostic value of type D in patients with coronary artery disease (CAD).

Methods

A total of 465 patients completed the Type D Scale (DS14) questionnaire before undergoing stent implantation and were followed up for 5 years.

Results

In a Cox regression model adjusted for selected confounders, we found a trend towards NA for the prediction of nonfatal major adverse cardiovascular event (MACE, hazard ratio (HR)?=?1.07, 95 % confidence intervals (CIs)?=?0.99?1.14, p?=?0.074), while, in contrast, SI was a significant and independent predictor of better outcome (HR?=?0.92, 95 % CI?=?0.86?0.99, p?=?0.027).

Conclusions

In a cohort of CAD patients, the type D pattern was not linked to adverse outcome, whereas SI was negatively associated with MACE.     

Communication about adherence to long-term antipsychotic prescribing: an observational study of psychiatric practice

Purpose

Partial or non-adherence is common in people taking antipsychotic medication. A good therapeutic alliance is thought by psychiatrists to encourage engagement with a service and improve adherence. This paper aims to examine how psychiatrists and patients communicate in outpatient consultations about partial or non-adherence to antipsychotic prescribing.

Methods

Ninety-two outpatient consultations involving patients prescribed antipsychotic medication and their psychiatrists were tape recorded. Parts of consultations where partial/non-adherence to antipsychotic medication was discussed were analysed using conversation analysis.

Results

In 22 (24 %) consultations, partial/non-adherence was disclosed. Most commonly, it was volunteered without prompting and was more likely to be presented as a deliberate choice than omission by the patient. Psychiatrists responded to all but one disclosure, and patients delivered their reports in ways that minimised the prospect of this response being disciplinary. The most common outcome was a change in prescribing: a medication omission, swap or dosage reduction.

Conclusions

Patients and psychiatrists work together to create a safe conversational environment in which to discuss this potentially difficult issue. Unlike previous studies of patient reports of psychotic symptoms and side effects of drowsiness being ignored, psychiatrists nearly always respond to disclosures of partial/non-adherence. Psychiatrists should apply the same listening skills to patients’ disclosures of troubling side effects and psychotic symptoms.     

Psychosocial Correlates of Atrial Natriuretic Peptide: A Marker of Vascular Health

Background

Psychosocial factors have been associated with cardiovascular outcomes, but few studies have examined the association between psychosocial function and natriuretic peptides.

Purpose

The purpose of this study is to determine the predictive value of hostility, anger, and social support in relation to atrial natriuretic peptide (ANP), a marker of vascular health, among middle-aged men.

Methods

One hundred twenty-one men (mean age?=?39.8 years, SD?=?4.1) underwent assessments of ANP and completed the Cook–Medley Hostility Scale, the Spielberger State–Trait Anger Scale, and the Interview Schedule for Social Interaction.

Results

Higher levels of hostility (β?=?0.22 [95 % CI 0.04, 0.40], P?=?0.032) and trait anger (β?=?0.18 [95 % CI 0.01, 0.37], P?=?0.044) were associated with greater ANP levels. In contrast, higher perceived social support was also associated with lower ANP levels, (β?=??0.19 [95 % CI ?0.05, ?0.41], P?=?0.010).

Conclusions

Psychosocial factors, including hostility, anger, and social support, are associated with varying ANP levels among middle-aged men, independent of cardiovascular and behavioral risk factors.     

Maternal smoking during pregnancy and neural tube defects in offspring: a meta-analysis

Purpose

This study aims to examine the association between maternal smoking during pregnancy and neural tube defects (NTDs) in offspring.

Methods

We retrieved published studies on the association between maternal smoking during pregnancy and NTDs risk in offspring. Meta-analysis was applied to calculate the overall odds ratios (ORs) and their 95 % confidence intervals (CIs). The publication bias was assessed by the Egger’s regression asymmetry test and Begg’s rank correlation test.

Results

The overall effect of maternal smoking during pregnancy on NTDs was 1.03 (OR?=?1.03, 95 % CI?=?0.80–1.33). When subgroup analysis was conducted by geographic regions, the overall effects were 1.39 (OR?=?1.39, 95 % CI?=?1.18–1.64), 0.88 (OR?=?0.88, 95 % CI?=?0.66–1.17) in Europe and USA; when subgroup analysis was conducted by NTDs types, the overall effect was 1.55 (OR?=?1.55, 95 % CI?=?1.06–2.26) for spina bifida.

Conclusions

Women who smoked during pregnancy had mildly elevated risk of having infants with NTDs.     

Predictors of prescribed medication use for depression,anxiety, stress,and sleep problems in mid-aged Australian women

Objective

The study examined prevalence of self-reported use of medication recommended or prescribed by a doctor for depression, anxiety, stress, and sleep problems; and modelled baseline factors that predicted use over 3 years for each condition.

Methods

Analyses were undertaken on the 2001 and 2004 surveys of mid-aged women in the Australian Longitudinal Study on Women’s Health. Dependent variables were self-reported use in past 4 weeks of medications recommended or prescribed by a doctor for depression, anxiety, stress, or sleep problems in 2001 and 2004. Generalized Estimating Equations (GEE) were used to predict medication use for each condition over 3 years.

Results

Prevalence of prescribed medication use (2001, 2004) for each condition was depression (7.2, 8.9 %), anxiety (7.4, 9.0 %), stress (4.8, 5.7 %), and sleep problems (8.7, 9.5 %). Multivariable analyses revealed that odds of medication use across 3 years in all four conditions were higher for women with poorer mental and physical health, using hormone replacement therapy (HRT), or having seen a counsellor; and increased over time for depression, anxiety, and stress models. Medication use for depression was also higher for overweight/obese women, ex-smokers, and unmarried. Medication use for anxiety was higher for unmarried and non-working/low occupational women. Medication use for stress was higher for non-working women. Additional predictors of medication for sleep were surgical menopause, and area of residence.

Conclusions

Self-reported use of prescribed medication for four mental health conditions is increased over time after controlling for mental and physical health and other variables. Research needs to explore decision-making processes influencing differential rates of psychoactive medication use and their relationship with health outcomes.