The use of individually tailored environmental supports to improve medication adherence and outcomes in schizophrenia.

Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
Schizophrenia Bulletin (Impact Factor: 8.61). 05/2008; 34(3):483-93. DOI: 10.1093/schbul/sbm111
Source: PubMed

ABSTRACT Cognitive adaptation training (CAT) is a psychosocial treatment that uses environmental supports such as signs, checklists, alarms, and the organization of belongings to cue and sequence adaptive behaviors in the home. Ninety-five outpatients with schizophrenia (structured clinical interview for diagnosis, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) were randomly assigned to (1) Full-CAT (CAT focused on many aspects of community adaptation including grooming, care of living quarters, leisure skills, social and role performance, and medication adherence), (2) Pharm-CAT (CAT focused only on medication and appointment adherence), or (3) treatment as usual (TAU). Treatment lasted for 9 months, and patients were followed for 6 months after the withdrawal of home visits. Medication adherence (assessed during unannounced, in-home pill counts) and functional outcomes were assessed at 3-month intervals. Results of mixed-effects regression models indicated that both CAT and Pharm-CAT treatments were superior to TAU for improving adherence to prescribed medication (P < .0001). Effects on medication adherence remained significant when home visits were withdrawn. Full-CAT treatment improved functional outcome relative to Pharm-CAT and TAU (P < .0001). However, differences for functional outcome across groups decreased following the withdrawal of home visits and were no longer statistically significant at the 6-month follow-up. Survival time to relapse or significant exacerbation was significantly longer in both CAT and Pharm-CAT in comparison to TAU (.004). Findings indicate that supports targeting medication adherence can improve and maintain this behavior. Comprehensive supports targeting multiple domains of functioning are necessary to improve functional outcomes. Maintenance of gains in functional outcome may require some form of continued intervention.

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    ABSTRACT: Background Non-adherence with antipsychotic medication is a frequently occurring problem, particularly among patients with psychotic disorders. Prior research has generally shown encouraging results for interventions based on `Contingency Management¿ (CM), in which desirable behaviour is encouraged by providing rewards contingent upon the behaviour. However, little is known about the application of CM on medication adherence in patients with psychotic disorders. An earlier pilot-study by our study group showed promising results in reducing admission days and increasing adherence. The current study is a randomized controlled trial concerning the effectiveness of a CM procedure called `Money for Medication¿ (M4M), aimed at improving adherence with antipsychotic depot medication in psychotic disorder patients.Methods/DesignOutpatients (n =168) with a psychotic disorder will be randomly assigned to either the experimental group (n =84), receiving a financial reward for each accepted antipsychotic medication depot, or the control group (n =84), receiving treatment as usual without financial rewards. Patients are included regardless of their previous adherence. The intervention has a duration of twelve months. During the subsequent six months follow-up, the effects of discontinuing the intervention on depot acceptance will be assessed.The primary goal of this study is to assess the effectiveness of providing financial incentives for improving adherence with antipsychotic depot medication (during and after the intervention). The primary outcome measure is the percentage of accepted depots in comparison to prescription. Secondary, we will consider alternative measures of medication acceptance, i.e. the longest period of uninterrupted depot acceptance and the time expired before depot is taken. Additionally, the effectiveness of the experimental intervention will be assessed in terms of psychosocial functioning, substance use, medication side-effects, quality of life, motivation, cost-utility and patients¿ and clinicians¿ attitudes towards M4M.DiscussionThis RCT assesses the effectiveness and side-effects of financial incentives in improving adherence with antipsychotic depot medication in patients with psychotic disorders. This study is designed to assess whether M4M is an effective intervention to improve patients¿ acceptance of their antipsychotic depot medication and to examine how this intervention contributes to patients¿ functioning and wellbeing.Trial Registration: NTR2350.
    BMC Psychiatry 12/2014; 14(1):343. · 2.24 Impact Factor
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    ABSTRACT: Background. Numerous studies have been conducted with a view to developing strategies for improvement of medical compliance in patients with schizophrenia. All of the studies conducted so far have had an individual approach to compliance based on the assumption that noncompliance is determined individually due to inappropriate behavior in the patient. We conducted a pragmatic controlled trial with a system-oriented approach, to provide a new perspective on compliance and test the efficacy of a multifactorial intervention at the system level in a routine clinical setting, an approach that has not previously been used for the improvement of compliance. Methods. 30 patients were allocated to the system-oriented therapy and 40 patients were allocated to the reference intervention, which consisted of individually based compliance therapy. The follow-up period was six months. Primary endpoint was improvement in compliance, measured by improvement in a compliance scale specifically developed for the project. Results. When accounting for missing values with a multiple imputation approach, we found a tendency toward a difference in both the compliance scale and PANSS favoring the system-oriented therapy, although it did not reach statistical significance. A significant difference in incidence of adverse events and time to first readmission was found. Attrition rates were significantly higher in the reference group and nonsignificant among individuals with lower compliance, which may have diluted effect estimates. This was reflected by significant differences found in an analysis based on a last observation carried forward approach. Conclusion. This study suggests that compliance problems are better solved by a multifactorial intervention at the system level than at the individual level.
    Schizophrenia research and treatment. 01/2014; 2014:789403.
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    ABSTRACT: Understanding determinants of antipsychotic medication adherence is critical as nonadherence plays a significant role in psychotic relapse and each relapse contributes to accrued social toxicity and disability. "Insight" or lack thereof and a negative medication attitude are critical variables that have repeatedly been shown to be risk factors for nonadherence. We examine how those risk factors can lead to nonadherence and describe evidence-based interventions to improve nonadherence. We also discuss newer approaches adapted from other branches of medicine that have shown some promise in increasing adherence to antipsychotics, specifically directly-observed-therapy (DOT) and providing financial incentives. Adherence-improving interventions need to be deployed in a stepped-up manner of increasing intensity and tailored to the specific etiologies of nonadherence. ANTIPSYCHOTIC NONADHERENCE Suboptimal adherence to antipsychotic medica-tions plays a major role in determining the frequent relapse and rehospitalization that is characteristic of schizophrenia. Antipsychotic medications are effec-tive in the treatment of acute episodes of psychosis (1) and in the prevention of relapse (2), reducing the risk of relapse in both first-episode (3) and chronic schizophrenia (4) patients. Although estimates of nonadherence vary widely depending on the sample, stage of illness, methodology used to assess adher-ence, and duration of follow-up, a recent review ar-ticle estimated that 41% of schizophrenia patients are nonadherent (5). It is important to note that in-sufficient adherence to medications is a pervasive problem in all of medicine (6). For example, ade-quate 2-year adherence to statins for the secondary prevention of further cardiac events was only 40% in a cohort of elderly patients following an acute coronary syndrome (7), suggesting widespread dif-ficulties adhering to maintenance medication in the general population and not just psychiatric pa-tient populations. However, while patients with schizophrenia share some risk factors for nonad-herence with medical patients (e.g. poor memory) they also pose specific challenges (e.g. lack of insight into illness). Understanding determinants of antipsychotic medication adherence in schizophrenia patients is critical as each psychotic relapse can contribute to ac-crued social toxicity and disability; or as Lieberman and Fenton put it, "untreated psychosis damages lives" (8). In addition to the undisputed social toxic-ity, some have argued that untreated psychosis may have neurotoxic effects (9), although there is currently limited evidence to support this theory and con-founding variables make this difficult to study (10). In this clinical review article, we will examine negative drug attitude and lack of insight as two important clinical risk factors for nonadherence in patients with schizophrenia and review interventions to improve adherence to antipsychotics.
    FOCUS: The Journal of Lifelong Learning in Psychiatry. 03/2012; 10(2).

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