WALID SARHAN F.R.C.Psych. Consultant psychiatrist AMMAN-JORDAN

Transcription

1 WALID SARHAN F.R.C.Psych. Consultant psychiatrist AMMAN-JORDAN

2 Compliance Definition: The extent to which a person s behaviour (in terms of taking medications, following diets or executing lifestyle changes) coincides with medical or health advice Terminology: Compliance Alliance Fidelity Adherence Concordance

3 One major difficulty in researching and assessing the magnitude of non- or poor adherence in schizophrenia is the lack of consistent and agreed upon definitions of this phenomenon Velligan DI, Lam Y-WF, Glahn DC, et al Defi ning and assessing adherence to oral antipsychotics: a review of the literature. Schizophr Bull, 32:

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5 إتباع التعليمات: Compliance التمسك وااللتزام Adherence: التوافق: Concordance المواظبة: Persistence

6 Non-satisfactory compliance Noncompliance Acceptable compliance Partial compliance 0% Adherence to prescribed treatment 100%

7 Defining levels of compliance Level of compliance Compliant Partially compliant Noncompliant Average of experts preferred definitions Patient misses < 25% of medication Patient misses 25% 65% of medication Patient misses > 65% of medication Kane et al, J Clin Psychiatry; 64, Suppl 12.

8 Reported extent of compliance Level of compliance Compliant (misses <20% of medication) Partially compliant (misses 20-80% of medication) Noncompliant (misses >80% of medication) Experts estimate of compliance levels in their patients 43% 38% 19% Kane et al, J Clin Psychiatry; 64, Suppl 12.

9 Source: Whitney HAK, Jr. et al. (Editors). Medication compliance: a healthcare problem. Annals of Pharmacotherapy 1993; 27 (9. Suppl).

10 Antipsychotics (3 24 months) (24 studies) Antidepressants ( months) (10 studies) Non-psychiatric ( months) (12 studies) Adherence (%) Wide range of estimates across studies may reflect difficulty of assessing covert nonadherence Data shown are mean and range Cramer & Rosenheck. Psychiatr Serv 1998;49:

11 The rate of non-adherence in patients with schizophrenia has been reported to be as high as 40% 50%(1) Weiden et al (2) reported that 74% of schizophrenic outpatients who are responsive to medications become noncompliant within 2 years post discharge. (1)-Lacro JP, Dunn LB, Dolder CR, et al Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. J Clin Psychiatry,63: (2)-Weiden P, Dixon L, Frances A Neuroleptic noncompliance in schizophrenia, in Advances in Neuropsychiatry and Psychopharmacology. Schizophr Res, 1:

12 Noncompliant Partially compliant Compliant Poor insight into illness Reminder of illness Forget (refuse?) to take medication Side effects Perceived poor quality of life (QoL) Loss of motivation Lack of psycho-education Oehl. Acta Psychiatr Scand. 2000;102(suppl 407):83-86.

13 not taking medication as prescribed - missing doses. - drug holidays. - lower dose.

14 20% reduction in medication adherence was found to predict a 3-point increase in scores on the positive and negative symptoms scores Docherty JP, Kozma C, Grogg A, et al Antipsychotic maintenance in schizophrenia: Partial compliance and clinical outcome. Am Coll Neuropsychopharmacol, 179.

15 A gap in treatment of 10 days or less over a 1-year period doubled the risk of hospitalization Weiden PJ, Kozma C, Grogg A, et al Partial compliance and risk of rehospitalization among California Medicaid patients with schizophrenia. [see comment]. Psychiatr Serv, 55:

16 % variance explained Poor insight Positive symptoms Diagnosis EPS, length of illness, social class etc Novak-Grubic & Tavcar. Eur Psychiatry 2002;17:148-54

17 Impact on illness Full Recovery Incomplete recovery Negative Symptoms Positive Symptoms Relapse Optimal Demoralization Loss of confidence Loss of job Family discord Rehospitalization Relapse Danger to self/others Days Weeks Months Duration of missed doses Keith & Kane J Clin Psychiatry, 2003; 64:

18 The person Age/gender Social status Cultural & family values Experiences of illness & treatment Support network & milieu Personality Insight/denial Intelligence Views of illness/role of med.

19 The Physician Beliefs / recommendations Dosing, follow up Education, attitude

20 The treatment Therapeutic alliance Treatment setting/inform. Effectiveness Complexity/supervision Side effects/satisfaction Stigma

21 The illness Substance use Delusional beliefs (paran., grand.,) Positive aspects of illness experience Depression / anxiety / cognitive. Duration

22 Addiction: long term sedation leaflets packaging Cost Internet

23 Weight Reduction Schizophrenia Exercise Flossing Hypertension Diabetes (insulin depot) Diabetes (oral) Depression Rheumatoid Arthritis Asthma Strep Throat Birth Control Pills Headache Easy Difficult Keith & Kane J Clin Psychiatry, 2003; 64:

24 Some of these are related to the illness, such as poor insight and cognitive dysfunction, while others are linked to the efficacy and tolerability profiles of the medications as well as the route of administration and dosing frequency. Other factors include co-morbid substance abuse Dixon L Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes. Schizophr Res, 35(Suppl): S

25 These include perceived benefit of treatment, fear of hospitalizations, desire to avoid unpleasant psychotic symptoms(1) Desire to please the psychiatrist or other members of the clinical team. A good therapeutic alliance will cultivate an environment for improved adherence (2) Better efficacy and fewer medication side effects will increase adherence as will simple medication regimens and a proper understanding of illness-associated symptoms and the nature of their response to treatment (3) (1) Weiden P, Rapkin B, Mott T, et al Rating of medication influences (ROMI) scale in schizophrenia. Schizophr Bull, 20: (2) Bebbington PE The content and context of compliance. Int Clin Psychopharmacol, 9(Suppl 5): (3) Degmecic D, Pozgain I, Filakovic P Psychoeducation and compliance in the treatment of patients with schizophrenia. Coll Antropol, 31:

26 Psycho-education of patients, families and carers Diagnosis/illness treatment possible side effects link between non-compliance- relapse-consequence of relapse Specialized clinics and regular contact between patients caregivers Effective medication with few side effects Use convenient formulations. 26

27 Medication Organizers Electronic Pager/Timers

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32 Adherence to antipsychotic medication is the single most important determinant of long-term clinical outcome in patients with schizophrenia. Those individuals who are willing and able to fully comply with their treatment regimen will likely maximize their chance of recovery and reduce their risk of relapse over the course of the illness. Michael Birnbaum Zafar Sharif 2008 Dove Medical Press Limited. Patient Preference and Adherence 2008:

33 Simplifying medication regimens as much as possible may help patients remain adherent. Whenever possible, medications should be administered once daily. Avoiding unnecessary polypharmacy and limiting the number of different medications to the minimum required for control of symptoms

34 Effective ways to help people follow medication regimens could have far larger effects on health than any other treatment Haynes et al. 2005

35 THANK YOU ANY QUESTIONS?

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