Self-reported treatment adherence among psychiatric in- and outpatients

Abstract

Background: Poor adherence to psychiatric treatment is a common clinical problem, leading to unfavourable treatment outcome and increased healthcare costs.

Aim: The aim of this study was to investigate the self-reported adherence and attitudes to outpatient visits and pharmacotherapy in specialized care psychiatric patients.

Methods: Within the Helsinki University Psychiatric Consortium (HUPC) pilot study, in- and outpatients with schizophrenia or schizoaffective disorder (SSA, n = 113), bipolar disorder (BD, n = 99), or depressive disorder (DD, n = 188) were surveyed about their adherence and attitudes towards outpatient visits and pharmacotherapy. Correlates of self-reported adherence to outpatient and drug treatment were investigated using regression analysis.

Results: The majority (78.5%) of patients reported having attended outpatient visits regularly or only partly irregularly. Most patients (79.2%) also reported regular use of pharmacotherapy. Self-reported non-adherence to preceding outpatient visits was consistently and significantly more common among inpatients than outpatients across all diagnostic groups (p?<?.001). Across all groups, hospital setting was the strongest independent correlate of poor adherence to outpatient visits (SSA β?=?–2.418, BD β?=?–3.417, DD β?=?–2.766; p?<?.001 in all). Another independent correlate of non-adherence was substance use disorder (SSA β?=?–1.555, p?=?.001; BD β?=?–1.535, p?=?.006; DD β?=?–2.258, p?<?.000). No other socio-demographic or clinical factor was significantly associated with poor adherence in multivariate regression models.

Conclusions: Irrespective of diagnosis, self-reported adherence to outpatient care among patients with schizophrenia or schizoaffective disorder, bipolar disorder, and depression is associated strongly with two factors: hospital setting and substance use disorders. Thus, detection of adherence problems among former inpatients and recognition and treatment of substance misuse are important to ensure proper outpatient care.     

Attitudes of schizophrenia outpatients toward psychiatric medications: relationship to clinical variables and insight

BACKGROUND: Attitude toward medications is important for medication adherence. A patient's drug attitude probably reflects a weighing of benefits against experienced or anticipated side effects or risks associated with the medication. We predicted (1) that drug attitudes would be more positive among schizophrenia patients taking second-generation compared to first-generation antipsychotics because of their greater tolerability and efficacy; and (2) that greater insight into illness, fewer extrapyramidal symptoms, and better social functioning would be associated with better attitudes toward psychiatric medication. METHOD: In a cross-sectional study of 81 DSM-IV-diagnosed schizophrenia outpatients, we used multivariate analysis to determine clinical and demographic predictors of drug attitude. Drug attitude was assessed with the 10-item Drug Attitude Inventory (DAI). The relationship between the DAI and psychopathology, insight, extrapyramidal symptoms, level of functioning, and type of antipsychotic (first-generation versus second-generation versus clozapine) was examined. RESULTS: Less awareness of current symptoms, presence of deficit symptoms, and employment predicted a negative attitude toward psychiatric medications. Extrapyramidal symptoms did not predict drug attitude. Drug attitudes were no different between patients taking first- or second-generation antipsychotics or clozapine. CONCLUSION: Patients may not favor second-generation over first-generation antipsychotics, and extrapyramidal symptoms may not be a primary factor determining attitudes. While attitudes may be more positive in patients who recognize therapeutic drug effects, patients who work may view medications particularly negatively, possibly due to a sense of stigma. Because drug attitudes may reflect compliance and are difficult to predict, clinicians should inquire directly.     

Folate levels in psychiatric outpatients

This study examines folate in psychiatric outpatients. Fifty-three outpatients with schizophrenia and 24 outpatients with depressive disorder assessed with the Schedules for Clinical Assessment in Neuropsychiatry interview are included. Patients with schizophrenia had lower serum folate levels than age- and sex-matched controls, while red cell folate levels did not differ. Serum folate levels showed a negative correlation with the Clinical Global Impression, disorganized dimension, and total Positive and Negative Syndrome Scale score. Patients with depressive disorder had lower serum folate levels than healthy controls, but showed no differences in red cell folate levels. Only two patients with schizophrenia had red cell folate levels below the normal range.     

Fertility in psychiatric outpatients.

The fertility rates of 223 female schizophrenic outpatients and 479 female nonschizophrenic outpatients were compared to a probability sample of 300 women residing in the same geographic area, metropolitan Atlanta, and from the same social strata as the patients. Age- and race-adjusted comparisons showed that the mean number of children per woman and levels of unwanted and unplanned fertility did not differ in the different diagnostic groups. Furthermore, the rates were not lower for the psychiatric patients than for the general population. In order to reduce an important source of psychiatric morbidity, those in the mental health professions need to pay more attention to the family planning desires of their patients.     

Relationships between demographic variables and quality of life in a population of Dutch adult psychiatric outpatients

Background Examinations of the role of demographic characteristics in quality of life (QOL) in psychiatric samples are not new. However, serious limitations of previous research have been that (1) QOL was not assessed according to current recommendations, (2) assessment of QOL was often hampered by a substantial overlap in content between symptoms and QOL measures, and (3) the majority of the study samples had quite specific characteristics hampering the generalizability of results, as a result of which clinical implications of the results remained unclear. The aim of the present study was to investigate explicitly the relationships between demographics and QOL in a sample reflecting the general population of psychiatric outpatients, QOL being assessed in a comprehensive, culturally sensitive, and subjective way, paying attention to the relative importance of its various facets. The main hypothesis was that these relationships would be rather weak.Method From a population of 533 adult Dutch psychiatric outpatients, 495 participants completed the World Health Organization Quality of Life (WHOQOL)-Bref for assessing QOL. Furthermore, several demographic characteristics were recorded.Results Statistically significant correlations were found between partner relationship, habitual status, work, and sick leave and the WHOQOL-Bref domains social relationships and environment. Psychological health was associated to partner relationship, educational level, and sick leave. The total amount of QOL variance explained by demographics was rather low.Conclusion Amongst factors determining QOL, demographic characteristics are relatively unimportant. Therefore, paying attention to demographics during psychiatric treatment will probably have little effect on improvement of QOL.     

The prevalence of DSM-IV personality disorders in psychiatric outpatients

OBJECTIVE: The largest clinical epidemiological surveys of personality disorders have been based on unstructured clinical evaluations. However, several recent studies have questioned the accuracy and thoroughness of clinical diagnostic interviews; consequently, clinical epidemiological studies, like community-based studies, should be based on standardized evaluations. The Rhode Island Methods to Improve Diagnostic Assessment and Services project is one of the largest clinical epidemiological studies to use semistructured interviews to assess a wide range of psychiatric disorders conducted in general clinical outpatient practice. In the present report, the authors examined the frequency of DSM-IV personality disorders in a patient group and the comorbidity among them. METHOD: Eight hundred fifty-nine psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality upon presentation for treatment. RESULTS: Slightly less than one-third of the patients were diagnosed with one of the 10 official DSM-IV personality disorders (N=270, 31.4%). When the patients with personality disorder not otherwise specified were included, the rate of any personality disorder increased to almost half of the group (N=391, 45.5%). The majority of patients meeting criteria for one of the specific personality disorders were diagnosed with more than one. Avoidant, borderline, and obsessive-compulsive personality disorder were the most frequent specific diagnoses. CONCLUSIONS: Personality disorders, as a group, are among the most frequent disorders treated by psychiatrists. They should be evaluated in all psychiatric patients because their presence can influence the course and treatment of the axis I disorder that patients typically identify as their chief complaint.     

Quality of life of schizophrenic psychiatric outpatients as a criterion for treatment planning in psychiatric institutions

BACKGROUND: Subjective quality of life (QoL) is an indispensable part of the current concept of health. Therefore it should serve as a criterion for treatment planning in social psychiatric institutions. AIM: We looked at the QoL of our outpatients diagnosed with schizophrenia in order to identify possible areas of life that might need further attention in treatment planning. METHODS: We used the short German version of the Lancashire Quality of Life Profile (BLEP-KF) to evaluate the QoL of 164 schizophrenic outpatients. All patients were diagnosed with the International Diagnostic Checklists (IDCL) for ICD-10. Demographic and treatment data are analysed cross-sectionally in relation to their QoL. RESULTS: The majority of patients was moderately happy with their general QoL. They were least satisfied in the domains of job and financial situation, mental health and sexuality. Psychopathology and especially the quality of individual care had a significant influence on the evaluation of QoL. CONCLUSION: This result supports an argument in favour of more individual patient-centred forms of case management to reduce the burden of severe psychopathological symptoms experienced in everyday activities by patients suffering from schizophrenia.     

Injury risk in young psychiatric outpatients

BACKGROUND: Studies investigating the association between injuries and mental health have mainly focused on mental health sequelae of injuries. The aim of this prospective cohort study was to assess the incidence and risk factors of physical injury hospitalisation and poisoning hospitalisation among adolescent psychiatric outpatients. SUBJECTS AND METHODS: Data on 302 consecutively referred Finnish psychiatric outpatients aged 12-22 years (mean 16) were collected at treatment entry. The end-point of the average 11-year follow-up was death or end of follow-up on 31 December 2005. The main outcome variables were physical injury hospitalisation and poisoning hospitalisation. RESULTS: Altogether 111 physical injury hospitalisations occurred in 65 (22% of all) persons during follow-up, incidence being 27.9 (95% CI: 22.7-33.1) per 1,000 person-years. Poisoning hospitalisation occurred in 22 (7.3%) persons, altogether 50 times, incidence being 12.6 (95% CI: 9.1-16.0). Seven injury-related deaths occurred, incidence being 1.8 (95% CI: 0.5-3.1) per 1,000 person-years. The most common physical injury types were fractures (40%), followed by distortions (10%) and wounds (10%), while poisoning for drugs accounted for 72% of the poisonings. Previous inpatient care, psychotropic medication, suicidality, and major depression were associated with poisoning hospitalisation during the follow-up while only gender was associated with physical injury hospitalisation. CONCLUSION: Injuries cause significant morbidity among psychiatric outpatients, but only poisonings seem to be related with suicidality in Finnish adolescent psychiatric outpatients. The high frequency of injuries seems to justify clinicians' attention to these aspects when assessing the need for care among young people.     

Anger and aggression in psychiatric outpatients

BACKGROUND: This study sought to evaluate the degree of anger and aggression experienced by psychiatric outpatients and to determine whether anger is as prominent an emotional state in these patients as are depression and anxiety. We also sought to determine which Axis I and Axis II disorders were associated with increased rates of subjective anger and aggressive behavior. METHOD: 1300 individuals presenting to a psychiatric outpatient practice underwent semistructured interviews to evaluate current DSM-IV Axis I (N = 1300) and Axis II disorders (N = 687). Levels of subjective anger and aggression during the preceding week were assessed in each patient, and the odds ratios were calculated for each disorder. A multiple regression analysis was performed to determine which psychiatric disorders independently contributed to the presence of subjective anger and aggressive behavior. RESULTS: Approximately one half of our sample reported currently experiencing moderate-to-severe levels of subjective anger, and about one quarter had demonstrated aggressive behavior in the preceding week. This level of anger was found to be comparable to the levels of depressed mood and psychic anxiety reported by our sample. Major depressive disorder, bipolar I disorder, intermittent explosive disorder, and cluster B personality disorders independently contributed to the presence of both anger and aggression. CONCLUSION: Anger and aggression are prominent in psychiatric outpatients to a degree that may rival that of depression and anxiety; it is therefore important that clinicians routinely screen for these symptoms.     

抑郁症患者首次至精神科首次就诊的特征

目的:调查精神科首诊抑郁症患者特征.方法:调查196例初次就诊精神科的抑郁症患者,对病程、就诊主动性、非精神科求治史等特征及其他相关因素进行分析. 结果:患者至精神科门诊初诊时平均病程(6.4±4.4)个月,仅37.6％患者主动来诊,46.7％曾求治过非精神科.逐步回归分析显示,影响初诊时病程的因素为性别、文化程度及发...     

Lormetazepam and amobarbital in the treatment of insomnia in psychiatric outpatients. A controlled study

During a double-blind clinical study, a new hypnotic benzodiazepine, lormetazepam (Wy 4082), was compared at a fixed dose of 1 mg to sodium amobarbital at a fixed dose of 100 mg for the treatment of moderate insomnia in 2 groups of 25 psychiatric outpatients. The medication was given at bedtime and the duration of the study was limited to 2 weeks. The quality of sleep was evaluated by the patient after the first night and at the end of the first and second week and by investigator at the end of the 2 weeks trial. The two products appeared effective on global assessment, but with an advantage in favour of lormetazepam: earlier onset of sleep and excellent acceptability on the final evaluation. Fifty two per cent of patients treated with amobarbital had side effects, mainly hangover and sedation during the morning, while only one patient treated with lormetazepam complained of headaches in the morning.     

Prevalence of dissociative disorders in psychiatric outpatients

OBJECTIVE: The purpose of the study was to assess the prevalence of DSM-IV dissociative disorders in an inner-city outpatient psychiatric population. METHOD: Subjects were 231 consecutive admissions (84 men and 147 women, mean age=37 years) to an inner-city, hospital-based outpatient psychiatric clinic. The subjects completed self-report measures of dissociation (Dissociative Experiences Scale) and trauma history (Traumatic Experiences Questionnaire). Eighty-two patients (35%) completed a structured interview for dissociative disorders (Dissociative Disorders Interview Schedule). RESULTS: The 82 patients who were interviewed did not differ significantly on any demographic measure or on the self-report measures of trauma and dissociation from the 149 patients who were not interviewed. Twenty-four (29%) of the 82 interviewed patients received a diagnosis of a dissociative disorder. Dissociative identity disorder was diagnosed in five (6%) patients. Compared to the patients without a dissociative disorder diagnosis, patients with a dissociative disorder were significantly more likely to report childhood physical abuse (71% versus 27%) and childhood sexual abuse (74% versus 29%), but the two groups did not differ significantly on any demographic measure, including gender. Chart review revealed that only four (5%) patients in whom a dissociative disorder was identified during the study had previously received a dissociative disorder diagnosis. CONCLUSIONS: Dissociative disorders were highly prevalent in this clinical population and typically had not been previously diagnosed clinically. The high prevalence of dissociative disorders found in this study may be related to methodological factors (all patients were offered an interview rather than only those who had scored high on a screening self-report measure) and epidemiological factors (extremely high prevalence rates for childhood physical and sexual abuse were present in the overall study population).     

门诊抗精神病药使用情况的调查

为了解门诊病人抗精神病药（ＡＰＤ）使用频度、治疗方案、药物副反应和疗效，采用分层随机方法抽取４８１例病人，用半定式表格填写自制的精神药物使用调查表。结果发现，门诊使用ＡＰＤ前３位药品为氯丙嗪、氯氮平及奋乃静，治疗方案前３位为氯丙嗪、氯氮平及氯丙嗪＋氯氮平；发现治疗剂量＜４００ｍｇ／ｄ组病人，药物副反应轻，疗效亦较好；单一治疗组副反应较合并及联合用药组轻，且疗效明显较好。有５３．６％的病人使用安坦，其中３７．２％的病人为预防性使用安坦。作者认为门诊病人尽量单一应用ＡＰＤ治疗，维持治疗剂量宜在４００ｍｇ／ｄ以下，不主张长期或预防性使用安坦。