The association of health literacy with illness perceptions,medication beliefs,and medication adherence among individuals with type 2 diabetes

Background

Beliefs in medications and illness perceptions is associated with medication adherence among individuals with diabetes and several adherence interventions focus on patients' beliefs in medicines and illnesses. Though health literacy is important in medication adherence, the relationship between health literacy and medication adherence remains inconclusive; thus raising the question as to whether health literacy has an amplifying or reducing effect on the relationship between beliefs and adherence.

Knowledge,attitudes and beliefs of patients and carers regarding medication adherence: a review of qualitative literature

Purpose

The aim of this review is to cohere evidence on the knowledge, attitudes and beliefs of patients and carers regarding medication adherence. Medication adherence refers to “the extent to which the patient’s action matches the agreed recommendations”. Medication adherence is vital in preventing, managing and curing illnesses and, hence, is linked with positive health outcomes.

Methods

A search was conducted using the following databases: CINAHL, Embase, PubMed and Web of Knowledge from inception to November 2013. Titles and abstracts were screened for inclusion in the review according to pre-defined inclusion and exclusion criteria. Studies were assessed for quality, and data were extracted into a data extraction form. Results were analysed thematically.

Results

The final results included 34 articles. Eight analytical themes were identified: (i) beliefs and experiences of medicines, (ii) family support and culture, (iii) role of and relationship with health-care practitioners, (iv) factors related to the disease, (v) self-regulation, (vi) communication, (vii) cost and (viii) access. The theme, “beliefs and experiences of medicines”, was present in 33 studies, with many discussing the influence that side effects have on medication adherence.

Conclusions

There are a number of variables that impact upon the knowledge, attitudes and beliefs of patients and carers regarding medication adherence. This review presents an overview of the analytical themes which offers the opportunity to examine interventions and their relative efficacies to increase medication adherence.     

Higher dopamine transporter density in Parkinson’s disease patients with depression

Rationale

Depression is a frequent non-motor symptom in Parkinson’s disease (PD) with increasing rates with the progression of the disease. Molecular imaging studies have shown a reduction of dopamine transporter (DAT) density in depressed PD patients (dPD); however, DAT role in the pathophysiology of PD depression is not clear since clinical matching was inappropriate and DAT reduction could be attributed to PD severity.

Objectives

To further examine the role of DAT in PD depression, this study compared thoroughly matched depressed vs. non-depressed PD patients (ndPD).

Materials and methods

Twenty PD patients (n?=?10 ndPD; n?=?10 dPD) matched for age and disease severity were submitted to brain SPECT imaging with [^99mTc]-TRODAT-1, a DAT radioligand. DAT-binding potential was calculated using regions of interest bilaterally drawn in the striatum, caudate, and putamen. Depression was defined according to Beck Depression Inventory (BDI; cut-off >18).

Results

Mean BDI scores were higher in dPD (25.0?±?5.6) than in ndPD patients (8.0?±?1.9, p?<?0.0001). DAT density was greater on dPD especially in the left caudate (dPD 0.87?±?0.19 vs. ndDP 0.69?±?0.18, p?=?0.02) and right putamen (dPD 0.37?±?0.07 vs. ndPD 0.28?±?0.13, p?=?0.03) than in ndPD patients.

Conclusion

Our results suggest that in vivo DAT density is increased in dPD patients as compared to ndPD, suggesting that DAT is implicated in the pathophysiology of PD depression.     

Sex difference in QTc prolongation in chronic institutionalized patients with schizophrenia on long-term treatment with typical and atypical antipsychotics

Objective

The rate-corrected electrocardiographic QT (QTc) interval may significantly increase in patients with schizophrenia taking antipsychotics. The objective of this naturalistic study was to assess the prevalence of prolonged QTc interval in a large population of inpatients with chronic schizophrenia and to explore QTc relationship with demographic variables and prescribed treatments.

Materials and methods

Electrocardiograms were obtained from age- and sex-matched 456 controls and 1,006 inpatients with schizophrenia (male/female?=?689/317) taking antipsychotics. QTc prolongation was defined as a mean value of two standard deviations above the controls. The adjusted relative risk was calculated using logistic regression analysis.

Results

QTc prolongation was present in 45 (4.5%) of 1,006 patients overall. Fewer men (3.2%, 22 of 689) than women (7.3%, 23 of 317) displayed QTc prolongation (p?<?0.004). Moreover, QTc intervals were shorter in male (391?±?31?ms) than female subjects (400?±?37?ms) (p?<?0.001). Clozapine was found to produce a longer QTc intervals compared to risperidone and typical antipsychotics. Furthermore, multiple regression analysis showed that significant predictors for QTc prolongation were comorbid cardiovascular disease, antipsychotic types, sex, and age (all p?<?0.01).

Conclusion

Our present findings suggest that there are sex differences in the prevalence of QTc prolongation and QTc lengthening in schizophrenia. Antipsychotic types are risk factors for QTc prolongation, and risks are substantially higher for clozapine.     

Diminished brain 5-HT transporter binding in major depression: a positron emission tomography study with [11C]DASB

Background

The serotonin transporter (5-HTT) plays a critical role in the regulation of serotonin neurotransmission and has been implicated in the pathophysiology of major depression. In a previous positron emission tomography study, we found no difference in brain 5-HTT binding between unmedicated recovered depressed patients and healthy controls.

Aim

This study aims to assess brain 5-HTT binding in a group of unmedicated acutely depressed patients in comparison to healthy controls.

Methods

We studied 5-HTT binding using [¹¹C]DASB in conjunction with positron emission tomography in 12 medication-free depressed patients with a mean duration of illness of about 1?year and 24 healthy controls.

Results

The depressed patients had lowered 5-HTT binding in several brain regions including brain stem, thalamus, caudate, putamen, anterior cingulate cortex and frontal cortex.

Conclusions

These results suggest that diminished availability of the 5-HTT in the brain may be a state marker of acute depression. Alternatively, low 5-HTT binding may delineate a group of depressed patients with a poor long-term prognosis.     

Risk factors for non-adherence to antidepressant treatment in patients with mood disorders

Purpose

Adherence to antidepressant therapy by patients with depressive disorders is essential not only to achieve a positive patient outcome but also to prevent a relapse. The aim of this study was to identify potential modelling factors influencing adherence to antidepressant treatment by patients with mood disorders in the community mental health care setting

Methods

A total of 160 consecutive psychiatric outpatients attending two Community Mental Health Centres on Tenerife Island between September 2011 and May 2012 were asked to participate in the study; of these, 145 accepted. The Morisky self-report scale was used to assess adherence. The potential predictors examined included socio-demographic, clinical and therapeutic variables. The Clinical Global Impression-Severity and -Improvement scales and the Beck Depression Inventory were used for clinical assessment. Drug treatment side-effects were assessed using the “Self-report Antidepressant Side-Effect Checklist.” All participants were also asked to complete the "Drug Attitude Inventory" (DAI), "Beliefs about Medicine Questionnaire" (BMQ), and "Leeds Attitude towards concordance Scale". Discriminant analyses were performed to predict non-adherence.

Results

There was no clear correlation between adherence and the socio-demographic variables examined, but adherence was related to a positive attitude of the patients towards his/her treatment (DAI) and low scores in the BMQ-Harm and -Concern subscales. Non-adherence was also related to an increasing severity of depression and to the presence and severity of side-effects.

Conclusions

Among our study cohort, the profiles of adherent patients to antidepressant treatment were more closely associated with each patient’s attitudes and beliefs than to objective socio-demographic variables. The severity of depression played a relevant role in adherence, but whether this role is direct or an interaction with several concurrent factors is not yet clear. Side-effects were also closely related to adherence, as conditioned by frequent polypharmacy.     

Burden of Upper Gastrointestinal Symptoms in Patients Receiving Low-Dose Acetylsalicylic Acid for Cardiovascular Risk Management

Background

Continuous low-dose acetylsalicylic acid (aspirin; ASA) is a mainstay of cardiovascular (CV) risk management. It is well established, however, that troublesome upper gastrointestinal (GI) symptoms are commonly experienced among low-dose ASA users.

Objective

The objective of this study was to investigate the occurrence of upper GI symptoms, and their impact on well-being, among patients taking low-dose ASA for CV risk management.

Study Design

This was a multicenter, non-interventional, 12-week study carried out in primary-care, cardiology, and practice group centers in the USA, Canada, and France.

Patients

Eligible patients were adults (age ≥18 years) at risk of or with confirmed CV disease, with physician-prescribed/-recommended low-dose ASA (75–325 mg) use.

Main Outcome Measures

An electronic device (eDiary) was used to collect patient-reported outcome data three times per day (morning, afternoon, and evening; regular reports), including upper GI (gastroesophageal disease [GERD]-like or dyspepsia-like) symptoms and the impact of such symptoms on sleep quality, perceived stress, and emotions. In addition to regular reports, patients were able to self-initiate a report of upper GI symptoms (spontaneous reports).

Results

Overall, 81,282 eDiary reports (including 4,407 spontaneous reports of upper GI symptoms) were collected from 340 patients. Upper GI symptoms (most commonly GERD-like) were commonly blamed on food/drink (39 %), and around one-third of patients (37 %) used medication to relieve their symptoms. Analysis showed that upper GI symptoms had a negative impact on sleep quality, perceived stress, and emotions (all p < 0.01). Overall, GI medication use was infrequent, but was more common among low-dose ASA-experienced patients (41 % vs. 12 % of evening reports in patients naïve to low-dose ASA at baseline; p < 0.01); adherence to prescribed daily proton pump inhibitors (PPIs) was poor (47 %).

Conclusion

Upper GI symptoms impact negatively on well-being among low-dose ASA users, in terms of decreased quality of sleep, increases in perceived stress, and negative impact on emotions. Despite this, patients may not necessarily associate these symptoms with their low-dose ASA therapy and do not readily take steps to manage such symptoms, which extends to poor adherence to prescribed daily PPIs.     

Impact of pharmaceutical care on health outcomes in patients with COPD

Background Chronic obstructive pulmonary disease (COPD) treatment goals are often not achieved despite the availability of many effective treatments. Furthermore, clinical pharmacist interventions to improve clinical and humanistic outcomes in COPD patients have not yet been explored and few randomized controlled trials have been reported to evaluate the impact of pharmaceutical care on health outcomes in patients with COPD. Objective The aim of the present study was to evaluate the impact of pharmaceutical care intervention, with a strong focus on self-management, on a range of clinical and humanistic outcomes in patients with COPD. Setting Outpatient COPD Clinic at the Royal Medical Services Hospital. Method In a randomised, controlled, prospective clinical trial, a total of 133 COPD patients were randomly assigned to intervention or control group. A structured education about COPD and management of its symptoms was delivered by the clinical pharmacist for patients in the intervention group. Patients were followed up at 6?months during a scheduled visit. Effectiveness of the intervention was assessed in terms of improvement in health-related quality of life, medication adherence, disease knowledge and healthcare utilization. Data collected at baseline and at the 6?month assessment was coded and entered into SPSS^? software version 17 for statistical analysis. A P value of <0.05 was considered statistically significant. Main outcome measure The primary outcome measure was health-related quality of life improvement. All other data collected including healthcare utilization, COPD knowledge and medication adherence formed secondary outcome measures. Results A total of 66 patients were randomized to the intervention group and 67 patients were randomized to the control group. Although the current study failed to illustrate significant improvement in health-related quality of life parameters, the results indicated significant improvements in COPD knowledge (P?<?0.001), medication adherence (P?<?0.05), medication beliefs (P?<?0.01) and significant reduction in hospital admission rates (P?<?0.05) in intervention patients when compared with control group patients at the end of the study. Conclusion The enhanced patient outcomes as a result of the pharmaceutical care programme in the present study demonstrate the value of an enhanced clinical pharmacy service in achieving the desired health outcomes for patients with COPD.     

5α-reductase type I expression is downregulated in the prefrontal cortex/Brodmann’s area 9 (BA9) of depressed patients

Rationale

The implications of the neurosteroid 3α-hydroxy-5α-pregnan-20-one [allopregnanolone (Allo)] in neuropsychiatric disorders have been highlighted in several recent clinical investigations. For instance, Allo levels are decreased in the cerebrospinal fluid (CSF) of patients with posttraumatic stress disorder (PTSD) and major unipolar depression. Neurosteroidogenic antidepressants [i.e., selective brain steroidogenic stimulants (SBSSs)], including fluoxetine and analogs, correct this decrease in a manner that correlates with improved depressive symptoms. Allo positively and allosterically modulates GABA action at postsynaptic and extrasynaptic GABA_A receptors. It is synthesized in both the human and rodent brain cortices by principal glutamatergic pyramidal neurons from progesterone by the sequential action of 5α-reductase type I (5α-RI), which is the rate-limiting step enzyme in Allo biosynthesis, and 3α-hydroxysteroid dehydrogenase (3α-HSD), which converts 5α-dehydroprogesterone into Allo.

Hypothesis

We thus hypothesized that decreased CSF levels of Allo in depressed patients could reflect a brain dysfunction of 5α-RI.

Methods

In a pilot study of samples from six patients per group [six depressed patients and six nonpsychiatric subjects (NPS)], we studied the expression of 5α-RI messenger RNA (mRNA) in prefrontal cortex Brodmann’s area 9 (BA9) and cerebellum from depressed patients obtained from the Maryland Brain Collection at the Maryland Psychiatric Research Center (Baltimore, MD) that were age-matched with NPS.

Results

The levels of 5α-RI mRNA were decreased from 25?±?5.8 in NPS to 9.1?±?3.1 fmol/pmol neuronal specific enolase (NSE) (t_1,10?=?2.7, P?=?0.02) in depressed patients. These differences are absent in the cerebellum of the same patients. The levels of neurosteroids were determined in the prefrontal cortex BA9 of depressed patients obtained from the Stanley Foundation Brain Bank Neuropathology Consortium, Bethesda (MD). The BA9 levels of Allo in male depressed patients failed to reach statistical difference from the levels of NPS (1.63?±?1.01 pg/mg, n?=?8, in NPS and 0.82?±?0.33 pg/mg, n?=?5, in nontreated depressed patients). However, depressed patients who had received antidepressant treatment (three patients SSRI and one TCA) exhibited increased BA9 Allo levels (6.16?±?2.5 pg/mg, n?=?4, t_1,9?=?2.4, P?=?0.047) when compared with nontreated depressed patients.

Conclusions

Although in a small number of patients, this finding is in-line with previous reports in the field that have observed an increase of Allo levels in CSF and plasma of depressed patients following antidepressant treatment. Hence, the molecular mechanisms underlying major depression may include a GABAergic neurotransmission deficit caused by a brain Allo biosynthesis downregulation, which can be normalized by SBSSs.     

A double-blind, placebo controlled, randomized trial of riluzole as an adjunct to risperidone for treatment of negative symptoms in patients with chronic schizophrenia

Rationale

Several recent studies have focused on glutamate modulating agents for symptoms relief in schizophrenia, especially negative symptoms which are resistant to conventional therapies.

Objectives

We aimed to assess the efficacy and tolerability of riluzole, an anti-glutamate agent with neuroprotective properties, as an adjunct to risperidone in improving negative symptoms of schizophrenia.

Methods

In this randomized double-blind placebo-controlled parallel-group study, 50 patients with chronic schizophrenia and a score of ≥20 on the negative subscale of positive and negative syndrome scale (PANSS) were enrolled in the active phase of their illness. Participants were equally randomized to receive riluzole (100 mg/day) or placebo in addition to risperidone (up to 6 mg/day) for 8 weeks. Participants were rated by PANSS every 2 weeks. The primary outcome of this study was the difference in the decrease of PANSS negative subscale score from baseline to the study endpoint between the two groups.

Results

By the study endpoint, riluzole-treated patients showed significantly greater improvement in the negative symptoms (P?<?0.001) as well as the PANSS total and general psychopathology subscale scores (P?=?0.001 and P?<?0.001; respectively) compared to the placebo group. Treatment group was the only significant predictor of changes in negative symptom in this trial (β?=??0.56, P?<?0.001). No significant difference was observed between two groups in the frequency of side effects.

Conclusion

These preliminary findings suggest that riluzole may be a safe and effective medication for the treatment of negative symptoms in patients with chronic schizophrenia. Further research and replication of study findings is warranted.

Clinical trial registry name and registration number

Iranian registry of clinical trials www.irct.ir, IRCT201107281556N26     

Epoetin alpha improves the response to antiviral treatment in HCV-related chronic hepatitis

Background

The conventional antiviral treatment of chronic hepatitis related to hepatitis C virus (HCV) often leads to anemia. In this case, it is necessary to reduce ribavirin dose or stop treatment, thus reducing the rate of sustained virological response.

Aim

We investigated whether epoetin alpha administration improves treatment adherence and leads to higher percentage of response at the end of therapy and sustained virological response.

Methods

Two hundred and fourteen individuals with genotype 1b HCV-related chronic hepatitis underwent treatment with pegylated (peg)-interferon alpha-2A 180 μg once weekly and ribavirin 1,000–1,200 mg/day; 174 were responders. Forty individuals completed treatment with no hemoglobin reduction; 134 developed anemia during therapy. Anemic responders were distributed randomly into two groups: group 1 continued therapy with epoetin alpha addiction; group 2 continued antiviral therapy with ribavirin reduction only.

Results

Patients in group 1 achieved better control of hemoglobin levels (13.8?±?1.2 g/dl at the end of therapy) than tthose in group 2 (11.5?±?0.8 g/dl). Sustained virological response was 59.7% in group 1 compared with 34.4% in group 2 (p?<?0.01).

Conclusions

In patients with 1b HCV-related chronic hepatitis who develop anemia during antiviral treatment, administration of epoetin alpha increases hemoglobin levels and the end-of-treatment rate and sustains virological response by improving treatment adherence.     

Structured pharmacist-led intervention programme to improve medication adherence in COPD patients: A randomized controlled study

Background

COPD is characterised by a progressive airflow limitation in the lungs. However, adherence to therapy improves management of symptoms and delays disease progression. Therefore, patients' knowledge and awareness about the disease are important. Hence, pharmacist-led educational interventions could achieve this and improve medication adherence.

Perceived Medication Assignment during a Placebo-Controlled Laboratory Study of Varenicline: Temporal Associations of Treatment Expectancies with Smoking-Related Outcomes

Rationale

Expectancies regarding treatment assignment may influence outcomes in placebo-controlled trials above and beyond actual treatment assignment. For smoking pharmacotherapies, guessing enrollment in the active medication treatment is associated with higher abstinence rates. However, placebo-controlled trials of smoking pharmacotherapies rarely assess perceived treatment assignment and those that do only collect this information after reaching full dosage.

Objectives

To determine the temporal relationship between treatment expectancies and smoking-related variables, we assessed the impact of treatment guess during a placebo-controlled laboratory study of varenicline on measures of craving, smoking reward, and smoking reinforcement. We hypothesized that treatment guess at mid-titration would influence smoking-related measures at full dosage, above and beyond actual medication effects. We also explored factors related to guess stability and differences in blind fidelity between mid-drug titration and full dosage.

Methods

Eighty-eight participants completed laboratory assessments at baseline, mid-titration, and full dosage that involved self-report and behavioral measures of tonic craving, cue-provoked craving, smoking reward, and smoking reinforcement. Participants guessed treatment assignment at mid-titration and full dosage.

Results

Generalized linear models confirmed that, beyond actual treatment assignment, treatment guess improved model fit for both self-report and behavioral smoking-related measures. Further, accuracy of treatment guess improved from titration to full dosage, and specific demographic factors (e.g., gender, race) were associated with type of treatment guess and guess stability across time.

Conclusions

These results reinforce the importance of assessing perceived treatment assignment repeatedly during placebo-controlled trials and suggest that treatment expectancies during titration can affect outcomes once full dosage has been reached.     

Lazy Sunday afternoons: the negative impact of interruptions in patients’ daily routine on adherence to oral antidiabetic medication. A multilevel analysis of electronic monitoring data

Purpose

Considerable variability in adherence over time exists. The aim of this study was to investigate to what extent deviations from the prescribed regimen in type 2 diabetes patients can be explained by characteristics of the individual ‘medication intake moments’ and the patient.

Methods

Medication intake of 104 non-adherent type 2 diabetes patients from 37 community pharmacies was electronically monitored for 6 months. The primary outcome measures were: (1) whether or not the intake occurred and (2) whether or not the intake occurred within the agreed-upon time period (correct timing). Multilevel logistic regression analyses were performed to account for the nested structure of the data.

Results

Medication intakes in the evening and during weekends and holidays were more likely to be incorrectly timed and also more likely to be completely missed. Irrespective of timing, most intakes occurred in the mornings of Monday through Thursday (96 %), and least intakes occurred on Saturday evening (82 %). Correctly timed intakes most often occurred on Monday and Tuesday mornings (61 %) in contrast to Sunday evenings (33 %). A patient’s medication regimen was significantly associated with adherence.

Conclusion

Based on our results, among patients who already have difficulties in taking their oral antidiabetic medication, interruptions in the daily routine negatively influence the intake of their medication. Professionals need to be aware of this variation in adherence within patients. As regular medication intake is important to maintain glycaemic control, healthcare professionals and patients should work together to find strategies that prevent deviations from the prescribed regimen at these problematic dosing times.     

Association of long-term adherence to evidence-based combination drug therapy after acute myocardial infarction with all-cause mortality. A prospective cohort study based on claims data

Purpose

To determine long-term adherence to evidence-based secondary preventive combination pharmacotherapy in survivors of acute myocardial infarction (AMI) and to investigate the association between adherence to recommended therapy and all-cause mortality in claims data.

Methods

Prospective cohort study based on claims data of an 18.75?% random sample of all persons insured with the local statutory health insurance fund AOK Hesse. Study population included patients with hospital discharge diagnoses of AMI between 2001 and 2005 excluding those who died within the first 30?days after AMI or who had been hospitalised with an AMI in the previous 2?years. A total of 3,008 patients were followed up until death, cancellation of insurance, or the end of the study period on 31 December 2007, whichever came first (median follow-up: 4.2?years).

Results

Drug adherence to single drug groups as determined by proportion of days covered ≥80?% was 21.8?% for antiplatelet drugs, 9.4?% for beta-blockers, 45.6?% for ACE inhibitors or angiotensin II receptor blockers and 45.1?% for lipid-lowering drugs. A total of 924 (39.7?%) patients met our definition of guideline adherence: Drugs available from three of four relevant drug groups on the same day for at least 50?% of the observation time. Of the patients adhering to the guidelines, 17.3?% died and of the non-adherents, 32.4?% died. All-cause mortality was 28?% lower for guideline-adherent patients than for the non-adherent group (adjusted HR 0.72, 95?% CI 0.60–0.86).

Conclusions

In everyday practice, post AMI patients benefit from guideline-oriented treatment, but the percentage of adherent patients should be improved.     

Effects of caffeine and alcohol on mood and performance changes following consumption of lager

Rationale

The present study examined whether caffeine would modify the behavioural effects of alcohol.

Objectives

The aim of the study was to determine whether caffeine modifies the effects of alcohol on mood and psychomotor performance and to identify possible dose–response and temporal relationships.

Methods

A double-blind study examined the effects of three successive lager drinks (330 ml each) in the early afternoon on mood and psychomotor performance assessed at 30-min intervals over a 2-h period. Participants carried out a baseline session and were then randomly assigned to one of six conditions formed by combining three different doses of caffeine (0, 62.5 and 125 mg per drink) with either no alcohol or 4.3 % alcohol. One hundred and forty-six young adults (65 male, 81 female; age range 18–30 years) participated in the study. Mood (alertness, hedonic tone and anxiety) was assessed before and after performing simple reaction time and choice reaction time tasks.

Results

Alcohol was associated with higher hedonic tone (p?<?0.005), reduced anxiety (p?<?0.05) and reduced alertness (p?<?0.005). Caffeine had no modifying effect on hedonic tone or anxiety. However, the highest dose of caffeine did remove the effect of alcohol on alertness (p?<?0.05). Effects of alcohol and caffeine were found on the performance tasks (all p values?<?0.05) but these were independent effects.

Conclusions

The results from the present study confirm that caffeine does not remove the negative effects of alcohol on performance although high doses counteract the drop in subjective alertness produced by alcohol.