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ABSTRACT: There are few psychosocial interventions specifically focused on improved treatment adherence in people with bipolar disorder (BD). Customized adherence enhancement (CAE) is a needs-based, manualized approach intended to improve medication adherence in individuals with BD. This was a six-month prospective trial of a CAE among 43 medication non-adherent individuals with BD who were receiving treatment in a community mental health clinic (CMHC).
CAE was flexibly administered in modules applied as indicated by an initial adherence vulnerabilities screening. Screening identified reasons for non-adherence and modules were then administered using pre-set criteria. CAE effects were evaluated at six-week, three-month, and six-month follow-up. The six-month follow-up was our primary time point of interest. The primary outcome was change from baseline in adherence using the Tablets Routine Questionnaire (TRQ) and pill counts. Secondary outcomes included change from baseline in BD symptoms [Hamilton Depression Rating Scale (HAM-D), Young Mania Rating Scale (YMRS), and Brief Psychiatric Rating Scale (BPRS)].
Subjects completed 86% of scheduled sessions, with only two individuals (5%) not participating in any sessions. The number of dropouts at six months was 12 (28%). Mean baseline non-adherence by TRQ was 48% [standard error (SE) 4.8%] missed tablets within the previous week and 51% (4.1%) missed tablets within the previous month. At six-month follow-up, mean TRQ non-adherence improved to 25% (6.8%) missed tablets for the previous week (p = 0.002) and 21% (5.5%) for the previous month (p < 0.001). Symptoms improved, with a change in the baseline mean (SE) BPRS of 43.6 (1.8) versus an endpoint of 36.1 (2.3) (p = 0.001), and baseline mean (SE) HAM-D of 17.8 (1.1) versus an endpoint of 15.3 (1.6) (p = 0.044).
CAE was associated with improvements in adherence, symptoms, and functional status. Controlled trials are needed to confirm these preliminary findings.
Bipolar Disorders 05/2012; 14(3):291-300. · 5.29 Impact Factor
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Journal of Geriatric Psychiatry and Neurology 03/2012; 25(1):4-5. · 3.07 Impact Factor
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ABSTRACT: This is an exploratory analysis of ambulatory and inpatient services utilization by older persons with type I bipolar disorder experiencing elevated mood. The association between type of treatment setting and the person's characteristics is explored within a framework that focuses upon predisposing, enhancing, and need characteristics.
Baseline assessments were conducted with the first 51 inpatients and 49 outpatients 60 years of age and older, meeting criteria for type I bipolar disorder, manic, hypomanic, or mixed episode enrolled in the geriatric bipolar disorder study (GERI-BD) study. We compared participants recruited from inpatient versus outpatient settings in regard to the patients' predisposing, enabling, and need characteristics.
Being treated in an inpatient rather than an outpatient setting was associated with the predisposing characteristic of being non-Hispanic caucasian (odds ratio [OR]: 0.1; P = .005) and past history of treatment with first-generation antipsychotics (OR: 6.5; P < .001), and the need characteristic reflected in having psychotic symptoms present in the current episode (OR: 126.08; P < .001).
Ethnicity, past pharmacologic treatment, and current symptom severity are closely associated with treatment in inpatient settings. Clinicians and researchers should investigate whether closer monitoring of persons with well-validated predisposing and need characteristics can lead to their being treated in less costly but equally effective ambulatory rather than inpatient settings.
Journal of Geriatric Psychiatry and Neurology 03/2012; 25(1):62-8. · 3.07 Impact Factor
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ABSTRACT: To identify baseline clinical factors associated with acute treatment response in depressed older adults with bipolar disorder (BD) receiving lamotrigine.
Secondary analysis of a multisite, 12-week, open-label, uncontrolled study of add-on lamotrigine in 57 adults 60 years and older with BD I or II depression. Measures included the Montgomery Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS). Cardiometabolic risk was measured with total serum cholesterol and the Cumulative Illness Rating Scale-Geriatric (CIRS-G) item #13 (endocrine/metabolic burden). Neurocognitive (executive) function was evaluated using the Trail Making Test.
Greater reduction in MADRS from baseline was associated with higher baseline cardiometabolic burden at 6 and 9 weeks and lower YMRS scores at 9 weeks. At 12 weeks, improvement in the MADRS from baseline was no longer significantly related to baseline cardiometabolic burden or YMRS scores. A longitudinal mixed model of MADRS scores corroborated these findings with a significant finding of time-by-baseline cholesterol level interaction. In a subset of participants, better baseline executive function was related to greater improvement in the MADRS at 9 weeks but not at 6 or 12 weeks. Among all participants, higher baseline YMRS scores were related to greater likelihood of dropout.
Lamotrigine appears to work best in depressed elderly patients with BD who have high cardiometabolic risk and low level of mania. Agents like lamotrigine that act primarily on neuroprogressive pathways involving oxidative stress, neurotrophins, and inflammation may be particularly effective in individuals with BD who have significant cardiometabolic burden because of their effects on shared vulnerability factors in BD and medical illness.
Journal of Geriatric Psychiatry and Neurology 03/2012; 25(1):37-42. · 3.07 Impact Factor
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ABSTRACT: There is a paucity of evidence on bipolar I acute symptoms' presentation in the elderly individuals compared to younger patients. The current literature provides little, and at times conflicting, information on age-related bipolar disorder (BD) symptom presentation. This article aims to compare symptom profile by age group among patients with bipolar I in an acute affective episode as evaluated in outpatient settings.
The current analyses include all Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) participants with a lifetime diagnosis of bipolar I disorder. We compared the presence and severity of acute mood elevation (mania and hypomania) and acute depression symptoms between younger (20-59 years old) and older individuals (older than or equal to 60 years).
With the exception of distractibility, all acute depression symptoms presented with comparable frequency and severity between younger and older individuals. No statistical significance was found regarding the presence of psychotic symptoms between the 2 groups, with symptoms reported by 11.2% of younger versus 9.4% older individuals, χ(2) (1, N = 1541) = 0.03, P = .74. No significant effects were found for mood elevation severity between the 2 age groups. Psychotic symptoms were reported in 12.7% versus 15.2%, χ(2) (1, N = 658) = 0.07, P = .65, and irritability in 97.7% versus 97.8%, χ(2) (1, N = 651) = 0.00, P = 1.00, in the younger and older group, respectively.
We found no statistically significant association between age and symptoms presentation of acute depression and mood elevation among patients with BD I. Acute BD I affective states present with similar profile and severity in old and young patients.
Journal of Geriatric Psychiatry and Neurology 03/2012; 25(1):6-14. · 3.07 Impact Factor
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ABSTRACT: A three-month prospective trial of a psychosocial intervention--customized adherence enhancement (CAE)--was conducted with 43 medication-nonadherent individuals with bipolar disorder.
CAE modules were administered as indicated by a screen that identifies reasons for nonadherence. The primary outcome was change in adherence to mood-stabilizing medications as measured by the Tablet Routines Questionnaire and pill counts. Secondary outcomes included change in symptoms, measured by the Hamilton Rating Scale for Depression (HAM-D), Young Mania Rating Scale (YMRS), and Brief Psychiatric Rating Scale (BPRS).
Participants completed 76% of sessions. Dropout at three months was 13 (30%). Adherence improved from a baseline mean±SD of 34%±27% of tablets missed in the past month to only 10%±15% (p<.001). BPRS, HAM-D, andYMRS scores all indicated significant improvement at three-month follow-up (p<.05).
Although conclusions must be tempered by the uncontrolled design, CAE appeared to be well accepted and was associated with improvements in adherence, symptoms, and functioning.
Psychiatric services (Washington, D.C.) 02/2012; 63(2):176-8. · 2.81 Impact Factor
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ABSTRACT: Communicating potential benefits and harm to patients and payers is essential for high-quality care. However, there are no published guidelines or consensuses on how to communicate potential benefits and harm to patients and payers.
The goal of this review was to identify key elements for communication between clinicians, patients, and payers to achieve maximal benefits and minimal risk.
Literature published from January 1980 to July 2011 and cited on MEDLINE was searched using the terms communication, benefit, harm, effectiveness, cost, cost-effectiveness, psychiatry, bipolar disorder, schizophrenia, and major depressive disorder. Elements related to communicating benefits and/or harm to patients and payers were identified, with only key elements discussed in detail here.
Evidence-based medicine, number needed to treat to benefit (NNTB) or harm (NNTH), and the likelihood of being helped or harmed (LHH) have been advocated as the basis for communication in all specialties of medicine. Phase-dependent communication of benefits and harm is novel, especially in patients with different phases of illness, such as bipolar disorder. Duration-dependent (short-term versus long-term) communication is essential for all psychiatric disorders to reduce the burden of relapse and adverse events with long-term treatment. For drugs with multiple therapeutic indications, a disease-dependent approach is crucial to maximize benefits and minimize harm. The exclusion of comorbid psychiatric disorders in pivotal efficacy trials affects their generalizability. Communicating cost (direct versus indirect) is an essential component in reducing health care expenditures. The results of available cost-effectiveness analyses of psychiatric pharmacotherapy have been inconsistent and/or contradictory.
Evidence-based communication of potential benefits and harm to patients and payers, using NNTB, NNTH, and LHH, should be the key principle that guides decision making. Phase-, duration-, and disease-dependent communication and evidence-based cost-saving principles can maximize benefit and reduce harm.
Clinical Therapeutics 12/2011; 33(12):B62-76. · 2.32 Impact Factor
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ABSTRACT: Diabetes and obesity among patients with serious mental illness are common. Use of second-generation antipsychotics compounds risk, and widely prevalent unhealthy behaviors further contribute to negative outcomes. This column describes Targeted Training in Illness Management, a group-based psychosocial treatment that blends psychoeducation, problem identification, goal setting, and behavioral modeling and reinforcement. The intervention has been adapted to the primary care setting and is targeted at individuals with serious mental illness and diabetes. A key feature of the intervention is the use of peer educators with serious mental illness and diabetes to teach and model self-management. Promising results from a 16-week trial are reported.
Psychiatric services (Washington, D.C.) 09/2011; 62(9):1001-3. · 2.81 Impact Factor
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ABSTRACT: It has been demonstrated that 46% to 48% of individuals with bipolar disorder (BD) are at least partially nonadherent with prescribed medication. Reports of whether male gender is a predictor of treatment nonadherence in BD have been inconsistent. The construct of gender may also be a matter of cultural orientation, and psychological gender, as a component of self-perception, may affect the experience of mental illness. Gender identity is the subjective experience of one's individuality as male or female.
This cross-sectional study evaluated gender and gender identity among men and women with BD as they relate to self-reported medication treatment adherence.
This secondary analysis of a larger study on treatment adherence evaluated men and women with BD being treated with mood-stabilizing medications in a community mental health clinic. Gender identity and treatment adherence were evaluated using the Bem Sex Role Inventory (BSRI) and the Tablets Routine Questionnaire, respectively. Other measures included assessing BD symptoms using the Hamilton Depression Rating Scale and mania symptoms using the Young Mania Rating Scale, as well as psychosocial support with the Interpersonal Support Evaluation List and locus of control with the Multidimensional Health Locus of Control Scale.
Mean age of the 70 men and 70 women with type I BD was 43.1 years for adherent patients and 40.8 years for nonadherent patients. Women with BD had mean scores on the BSRI consistent with general population norms, whereas men with BD had scores suggesting lower levels of self-perceived masculinity than population norms. There were no differences between men and women on adherence; however, men with high BSRI masculinity scores had less adherence than other men in the sample (P = 0.04). Lower scores on the "powerful others" dimension of locus of control were associated with lower adherence. For women, there was no relationship between BSRI masculinity scores and adherence.
Gender identity in men with BD differed from general population norms and appeared to be related to adherence. Treatment approaches that are intended to optimize adherence need to consider the construct of gender identity or gender role. ClinicalTrials.gov ID: NCT00183495.
Gender Medicine 08/2011; 8(4):261-8. · 2.10 Impact Factor
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ABSTRACT: Because the elderly are the fastest growing segment of the population, the number of older adults with bipolar disorder is increasing. Geriatric bipolar disorder is relatively rare, with an estimated lifetime prevalence of 0.5% to 1%, although approximately 4% to 17% of older patients in clinical psychiatric settings have bipolar disorder. Bipolar elders are disproportionately affected by medical burden. Given the complex nature of this disorder, comorbidity, and behavioral disturbances, various interventions may be indicated, including pharmacotherapies, electroconvulsive therapy, psychotherapies, and integrated care models. Additional research is needed to better understand the epidemiology, phenomenology, and treatment of geriatric bipolar disorder.
The Psychiatric clinics of North America 06/2011; 34(2):319-33, vii. · 1.87 Impact Factor
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ABSTRACT: This is a multisite, 12-week, open-label trial of lamotrigine augmentation in 57 older adults (≥ 60 years; mean ± SD age = 66.5 ± 6.7 years) with either type I or type II bipolar depression.
Primary outcome measure was change from baseline on the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary outcome measures included Hamilton Depression Rating Scale (HAM-D), Clinical Global Impression-Bipolar version (CGI-BP), and the WHO-Disability Assessment Schedule II (WHO-DAS II). The Udvalg for Kliniske Undersøgelser (UKU) was used to assess side effects.
A total of 77.2% of the study subjects had bipolar I disorder. The mean (SD) lamotrigine dose was 150.9 (68.5) mg/day. There was significant improvement in the MADRS, HAM-D, CGI-BP, and in most domains on the WHO-DAS II. For patients for whom final MADRS score was available: 31 (57.4%) met remission criteria and 35 (64.8%) met response criteria. There were 19/57 (33.3%) who dropped out of the study prematurely, with 6 dropouts due to adverse events (4 cases of rash, 1 manic switch, and 1 hyponatremia). Two cases of rash were possibly drug related and were resolved with drug discontinuation. The most common UKU adverse effects were reduced sleep duration (n = 14, 24.6%), weight loss (n = 12, 21.1%), increased dream activity (n = 12, 21.1%), polyuria/polydipsia (n = 11, 19.3%), weight gain (n = 9, 15.8%), diminished sexual desire (n = 9, 15.8%), increased sleep (n = 9, 15.8%), lassitude/fatigue (n = 8, 14%), and unsteady gait (n = 8, 14%). No significant changes in electrocardiogram or laboratory tests were observed.
In bipolar depressed elders, lamotrigine was associated with improvement in depression, psychopathology, and functional status. There was a moderate number of adverse events, although relationship of adverse events (particularly falls) to study medication could not be clearly determined in this uncontrolled trial. Controlled studies are needed to further evaluate efficacy and tolerability of lamotrigine therapy in geriatric bipolar depression.
Bipolar Disorders 05/2011; 13(3):294-302. · 5.29 Impact Factor
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ABSTRACT: OBJECTIVE: Given the paucity of information available regarding standardized ratings of depression symptoms in bipolar manic states, and in particular those in older adults, we explored depression ratings in symptomatic participants in a multicenter study of treatment of bipolar I disorder in late life. METHODS: Baseline data was obtained from the first 100 patients enrolled in an NIMH-funded, 9-week, randomized, double-blind RCT comparing treatment with lithium or valproate in patients of age 60 years and older with Type I Bipolar mania or hypomania. This multi-site study was conducted at six academic medical centers in the United States and enrolled inpatients and outpatients with a total Young Mania Rating Scale (YMRS) score of 18 or greater. Depressive symptoms were evaluated with the Hamilton Depression Rating Scale (HAM-D) and the Montgomery-Asberg Depression Rating Scale (MADRS). The criterion for at least moderate bipolar depressive symptoms was the European College of Neuropsychopharmacology (ECNP) Consensus Meeting definition of HAM-D 17 total score >20. RESULTS: Eleven percent of patients had mixed symptoms defined by depression scale severity according to ECNP criterion. In the overall sample, total scores on the two depression scales were highly correlated. Total YMRS scores of this mixed symptom group were similar to the remainder of the sample. CONCLUSIONS: These preliminary findings suggest that moderate to severe depressive symptoms occur in about one in ten bipolar manic elders. Future studies are needed to further evaluate symptom profiles, clinical correlates, and treatments for bipolar older adults with combined manic and depressive symptoms. Copyright © 2011 John Wiley & Sons, Ltd.
International Journal of Geriatric Psychiatry 03/2011; · 2.42 Impact Factor
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ABSTRACT: Latinos, and Puerto Ricans in particular, have been disproportionately impacted by HIV/AIDS. Severe mental illness (SMI) is associated with an increase in HIV risk. Relatively little research has focused on the role of SMI among Puerto Rican injection drug users (IDUs) and non-IDUs in susceptibility to and transmission of HIV and there are few published reports on HIV risk among Latina SMI. We conducted a longitudinal mixed methods study with 53 Puerto Rican women with schizophrenia, bipolar disorder, or major depression to examine the cultural context of HIV risk and HIV knowledge, beliefs, and behaviors among a larger study with Puerto Rican and Mexican women with serious mental illness (SMI). There was a high prevalence of past and current substance use and a high prevalence of substance use-associated HIV risk behaviors, such as unprotected sexual relations with an IDU. The violence associated with substance use frequently increased participants' HIV risk. Choice of substance of abuse depended on cost, availability, and use within the individual participant's network. Participants attributed their substance use to the need to relieve symptoms associated with their mental illness, ameliorate unpleasant feelings, and deaden emotional pain. HIV prevention interventions for poorer Puerto Rican women with SMI must target the individuals themselves and others within their networks if the women are to be supported in their efforts to reduce substance use-related risk. The content of any intervention must address past and current trauma and its relationship to substance use and HIV risk, as well as strategies to prevent HIV transmission.
Journal of Immigrant and Minority Health 02/2011; 13(4):681-9. · 1.16 Impact Factor
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ABSTRACT: Nonadherence to medications for mental disorders substantially limits treatment effectiveness and results in higher rates of relapse, hospitalization, and disability. Accurate measurement of medication adherence is important not only in adherence research but also in clinical trials in which medications are being evaluated and in clinical practice where failure to detect nonadherence results in premature medication changes, unnecessary polypharmacy, and greater likelihoods of functional deteriorations and hospitalizations. This is a review of psychiatric treatment adherence methods and measures arising from a meeting on "Methodological Challenges in Psychiatric Treatment Adherence Research" held on September 27-28, 2007, in Bethesda, MD, and organized by the National Institute of Mental Health (NIMH).
This paper reviews the range of modalities currently available for assessing adherence behavior including pill counts, pharmacy records, technology-assisted monitoring, biological assays, and a range of self-report and interviewer-rated scales. Measures of adherence attitudes are also reviewed.
Each of the adherence measures described are imperfect estimates of actual medication ingestion, but each provides informative estimates of adherence or the attitudinal factors associated with adherence. Measure selection depends on a range of factors including the patient sample, the context in which the measure is being used, and the clinical outcomes expected from various levels of nonadherence. The use of multiple measures of adherence is encouraged to balance the limitations of individual measures.
While adherence assessment has become increasingly sophisticated in recent years, there remains a need for refinement and expansion on currently available methods and measures.
Journal of psychosomatic research 12/2010; 69(6):591-9. · 2.91 Impact Factor
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ABSTRACT: We describe the cognitive function of older adults presenting with bipolar disorder (BD) and mania and examine whether longer lifetime duration of BD is associated with greater cognitive dysfunction. We also examine whether there are negative, synergistic effects between lifetime duration of BD and vascular disease burden on cognition.
A total of 87 nondemented individuals with bipolar I disorder, age 60 years and older, experiencing manic, hypomanic, or mixed episodes, were assessed with the Dementia Rating Scale (DRS) and the Framingham Stroke Risk Profile (FSRP) as a measure of vascular disease burden.
Subjects had a mean (SD) age of 68.7 (7.1) years and 13.6 (3.1) years of education; 50.6% (n = 44) were females, 89.7% (n = 78) were white, and 10.3% (n = 9) were black. They presented with overall and domain-specific cognitive impairment in memory, visuospatial ability, and executive function compared to age-adjusted norms. Lifetime duration of BD was not related to DRS total score, any other subscale scores, or vascular disease burden. FSRP scores were related to the DRS memory subscale scores, but not total scores or any other domain scores. A negative interactive effect between lifetime duration of BD and FSRP was only observed with the DRS construction subscale.
In this study, lifetime duration of BD had no significant relationship with overall cognitive function in older nondemented adults. Greater vascular disease burden was associated with worse memory function. There was no synergistic relationship between lifetime duration of BD and vascular disease burden on overall cognition function. Addressing vascular disease, especially early in the course of BD, may mitigate cognitive impairment in older age.
Bipolar Disorders 12/2010; 12(8):851-8. · 5.29 Impact Factor
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ABSTRACT: We describe the increasing prevalence of chronic illnesses such as obesity and type 2 diabetes have markedly increased in both developed and developing countries. We describe the relationship between type 2 diabetes and mental illness. The extant literature suggests a critical need for innovative treatments targeted to individuals with comorbid diabetes and mental illness. Given the complexity and challenge of both of these disorders in tandem with the interactive challenges and burdens of psychiatric and medical comorbidity, it is essential that interventions address the issue of mental and medical health from the perspective of the individual with the disorder, engage individuals to actively participate in illness self-management, and include consideration of the multiple barriers to care.
Psychiatria Danubina 11/2010; 22 Suppl 1:S4-5. · 0.44 Impact Factor
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ABSTRACT: Some populations appear to be particularly vulnerable to the development of psychiatric symptomatology related to life events and biologic or social/cultural factors. Such groups include individuals who have experienced traumatic events, military personnel, individuals with serious medical conditions, postpartum women, and immigrants. This study reviews the literature regarding primary prevention of psychiatric disorders in special populations and identifies a variety of universal, selective, and indicated prevention measures aimed at minimizing the psychiatric sequelae in these groups.
The authors reviewed the literature regarding the prevention of psychiatric symptoms in trauma/abuse victims, individuals in the military, oncology patients, patients with diabetes, pregnant/postpartum women, and immigrants.
The literature on primary prevention of psychiatric illness in the special populations identified is rather limited. Universal prevention may be beneficial in some instances through public awareness campaigns and disaster planning. In other instances, more specific and intensive interventions for individuals at high risk of psychiatric illness may improve outcomes, for example, crisis counseling for those who have experienced severe trauma.
Primary prevention of psychiatric illness may be an attainable goal via implementation of specific universal, selected, and indicated primary prevention measures in special populations.
Annals of Clinical Psychiatry 11/2010; 22(4):262-73. · 1.49 Impact Factor
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ABSTRACT: This is a review of adherence determinants in bipolar disorder based on published prospective studies. Patient, treatment, and systems-level adherence determinants are summarized. The review concludes with recommendations on approaches that may minimize nonadherence. MEDLINE, PsychINFO, and the Cochrane Database were searched using key terms of adherence, compliance, or persistence, combined with terms of bipolar disorder, bipolar depression, or mania. Publications were filtered for randomized clinical trials (RCTs). Due to low yields of RCTs, we additionally included prospective nonrandomized clinical and epidemiologic studies, and prospective studies of severe mental illness that had a focus on adherence as an outcome and reported data separately for bipolar disorder. A targeted review of the broader bipolar literature provided background for concluding remarks. Twenty-two publications were identified describing RCTs with a specific population of bipolar disorder and a measure of adherence. Additional prospective nonrandomized studies were also identified. Studies identified three major categories of factors important to adherence: patient, treatment, and systems-associated factors. Patient factors include selected demographic features, symptom severity and phase of illness, presence of past suicide attempts, psychiatric comorbidity, illness and treatment duration, and relationship with providers. Treatment factors include type and intensity of pharmacotherapy and psychotherapy. Systems-level factors include differential levels of care access and costs. There is an overall lack of RCTs, and few prospective studies, on patient and systems-related determinants of adherence. Treatment-related determinants of adherence have the most evidence to date; however, would benefit from larger studies with diverse populations. Careful assessment of treatment adherence (including partial adherence) should be included in all prospective bipolar treatment studies, and studies should be conducted to prospectively evaluate interventions to minimize nonadherence.
CNS Neuroscience & Therapeutics 10/2010; 16(5):308-15. · 4.44 Impact Factor
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ABSTRACT: Poor adherence to medication can have devastating consequences for patients with serious mental illness. The literature review and recommendations in this article are reprinted from The Expert Consensus Guideline Series: Adherence Problems in Patients with Serious and Persistent Mental Illness, published in 2009. The expert consensus survey (39 questions, 521 options) on adherence problems in schizophrenia and bipolar disorder was completed by 41 experts in 2008. This article first reviews the literature on interventions aimed at improving adherence. It then presents the experts' recommendations for targeting factors that can contribute to nonadherence and relates them to the literature. The following psychosocial/programmatic and pharmacologic interventions were rated first line for specific problems that can lead to nonadherence: ongoing symptom/ side-effect monitoring for persistent symptoms or side effects; services targeting logistic problems; medication monitoring/environmental supports (e.g., Cognitive Adaptation Training, assertive community treatment) for lack of routines or cognitive deficits; and adjusting the dose or switching to a different oral antipsychotic for persistent side effects (also high second-line for persistent symptoms). Among pharmacologic interventions, the experts gave high second-line ratings to switching to a long-acting antipsychotic when lack of insight, substance use, persistent symptoms, logistic problems, lack of routines, or lack of family/ social support interfere with adherence and to simplifying the treatment regimen when logistic problems, lack of routines, cognitive deficits, or lack of family/social support interfere with adherence. Psychosocial/programmatic interventions that received high second-line ratings in a number of situations included medication monitoring/environmental supports, patient psychoeducation, more frequent and/or longer visits if possible, cognitive behavioral therapy (CBT), family-focused therapy, and services targeting logistic problems. It is important to identify specific factors that may be contributing to a patient's adherence problems in order to customize interventions and to consider using a multifaceted approach since multiple problems may be involved.
Journal of psychiatric practice. 09/2010; 16(5):306-24.
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ABSTRACT: Epilepsy is a neurological disorder primarily characterized by recurrent, unprovoked seizures resulting from excessive or synchronous neuronal activity in the brain. Depending on the case definition and population studied, the lifetime prevalence of epilepsy in the USA is estimated to be 1.2 - 2.9%. In general, epilepsy is related to a significant increased risk of mortality and injury. A cornerstone of epilepsy management is use of antiepileptic drugs (AEDs). This review focuses on the AED lamotrigine, with particular emphasis on the extended-release formulation, in the management of patients with epilepsy, and the significant clinical issues that may be relevant with once-daily AED therapy.
An introductory section overviews the prevalence of epilepsy, current treatment recommendations for patients with epilepsy, and unmet needs in epilepsy management. This is followed by an overview of the AED market with currently available and developing compounds, a summary of lamotrigine and extended-release lamotrigine, clinical efficacy and tolerability studies with extended-release lamotrigine, and regulatory issues. The review concludes with an expert opinion summary on the important issue of treatment adherence, the possible role of extended-release lamotrigine in adherence enhancement, and additional research and areas which need further focus for optimal epilepsy outcomes.
The reader will gain familiarity with extended-release (once-daily) lamotrigine and clinical issues that may be relevant to once-daily use. Once-daily AED use might be one way to simplify the epilepsy treatment regimen and can pave the way for other approaches that can maximize adherence, such as a frank discussion of risks, benefits, and attitudes towards treatment - all critical components of a strong and positive doctor-patient relationship. Take home message: The AED lamotrigine is widely used in clinical settings and has become available in a once-daily extended-release version, which may minimize serum concentration fluctuation and presumably would both reduce patient burden and maximize treatment adherence as opposed to the immediate-release version of the compound. Adverse effects and safety concerns between the immediate- and extended-release versions of lamotrigine seem similar based upon interpretation of the limited literature.
Expert Opinion on Pharmacotherapy 06/2010; 11(9):1579-85. · 3.20 Impact Factor
