Comparison of patient and clinician perspectives in the assessment of antipsychotic medication adherence.

BACKGROUND: Factors influencing patient and clinician perspectives in the assessment of medication adherence have never been compared. METHOD: This study used baseline and 12-month follow-up data from the QUATRO study, an international multicentre study. At baseline, information on patient sociodemographic characteristics, treatment factors, psychopathology, functioning and experience of antipsychotic side effects was gathered. After 12 months of follow-up, psychopathology, functioning and patient experience of antipsychotic side effects were measured once more, and a patient and clinician rating of adherence was obtained by means of the Medication Adherence Rating Scale (MARS) and the Compliance Rating Scale (CRS). RESULTS: During the recruitment period, 409 subjects with a diagnosis of schizophrenia were recruited. Patients were more often men and single. Mean age was 41.5 years. At the time of the assessment, more than 40% were unemployed and on average had been on antipsychotic treatment for more than 10 years. Nearly 70% were receiving second-generation antipsychotics, and 50% received adherence therapy during the 12 months after enrollment. The relationship between the MARS and the CRS scores showed only a small overlap (correlation coefficient = 0.26). In the multivariate model, the only factor significantly associated with both patient and clinician ratings of adherence was psychopathology. Unemployment and poor subjective tolerability of antipsychotics were significantly associated with low levels of patient ratings of adherence. Conversely, length of treatments and use of newer antipsychotics were significantly associated with better clinician ratings of adherence. CONCLUSION: Patient and clinician ratings of adherence do not measure the same dimension. Factors that may positively affect adherence in terms of compliance with prescribed medication regimens may not affect patients' views on adherence, and this should be taken into consideration when planning and negotiating treatment modalities with each individual patient suffering from schizophrenia.

An empirical method to identify patterns in the course of psychotic episodes of people with schizophrenia.

OBJECTIVE: This paper illustrates the process of constructing, selecting and applying simple measures in order to empirically derive patterns of course of psychotic episodes in schizophrenia. METHOD: Data were collected with a composite instrument constructed for a multi-centre, follow-up randomized controlled trial of adherence therapy for people with schizophrenia. The instrument included a retrospective weekly assessment of psychotic/non-psychotic status, which was used to derive the measures, and the DSM-IV course specifiers. RESULTS: The measures discriminated well between different course patterns and identified homogeneous clusters of subjects which correlated with the groups derived from the DSM-IV course specifiers. CONCLUSIONS: The new measures provide an empirical basis to identify specific patterns of course and to differentiate patients according to pre-defined criteria. They can be used in follow-up studies as measures of outcome, to investigate correlations between variables and to identify potential predictors of outcome.

SF-36 scales, and simple sums of scales, were reliable quality-of-life summaries for patients with schizophrenia.

OBJECTIVE: To examine the feasibility and reliability of the Medical Outcomes Study 36 Item Short Form Health Survey (SF-36) for patients with schizophrenia, focusing on the eight scales and various aggregate summary measures. STUDY DESIGN AND SETTING: Secondary analysis of data from the European multicenter QUATRO medication adherence trial and the Regional Psychosis Project from The Netherlands. Methods included exploratory and confirmatory factor analyses and estimation of aggregate score reliability using Cronbach's alpha and Tarkkonen's generalized reliability index. The aggregate scores that were compared included two sets based on factor analyses, the standard "physical and mental health component summary scores" (PCS and MCS) and scores based on the original conceptual model of the SF-36 (simple sum of first four scales for physical health, last four for mental health). RESULTS: The eight SF-36 scales were feasible to administer and reliable. Factor analyses of the QUATRO baseline scale data suggested two or three factors, the latter solution including a general "role limitation" factor. Aggregate scores based on the conceptual model had the highest generalized reliability of those compared. CONCLUSION: SF-36 scales are suitable for patients with schizophrenia. Aggregate scores based on the conceptual model may be preferable to the MCS and PCS for such patients. Further investigation of factor structure is advisable.

An investigation of factors associated with psychiatric hospital admission despite the presence of crisis resolution teams.

BACKGROUND: Crisis resolution teams (CRTs) provide a community alternative to psychiatric hospital admission for patients presenting in crisis. Little is known about the characteristics of patients admitted despite the availability of such teams. METHODS: Data were drawn from three investigations of the outcomes of CRTs in inner London. A literature review was used to identify candidate explanatory variables that may be associated with admission despite the availability of intensive home treatment. The main outcome variable was admission to hospital within 8 weeks of the initial crisis. Associations between this outcome and the candidate explanatory variables were tested using first univariate and then multivariate analysis. RESULTS: Patients who were uncooperative with initial assessment (OR 10.25 95% CI-4.20-24.97), at risk of self-neglect (OR 2.93 1.42-6.05), had a history of compulsory admission (OR 2.64 1.07-6.55), assessed outside usual office hours (OR 2.34 1.11-4.94) and/or were assessed in hospital casualty departments (OR 3.12 1.55-6.26), were more likely to be admitted. Other than age, no socio-demographic features or diagnostic variables were significantly associated with risk of admission. CONCLUSION: With the introduction of CRTs, inpatient wards face a significant challenge, as patients who cooperate little with treatment, neglect themselves, or have previously been compulsorily detained are especially likely to be admitted. The increased risk of admission associated with casualty department assessment may be remediable.

Bias in psychiatric case-control studies: literature survey.

BACKGROUND: Case-control studies are vulnerable to selection and information biases which may generate misleading findings. AIMS: To assess the quality of methodological reporting of case-control studies published in general psychiatric journals. METHOD: All the case-control studies published over a 2-year period in the six general psychiatric journals with impact factors of more than 3 were assessed by a group of psychiatrists with training in epidemiology using a structured assessment devised for the purpose. The measured study quality was compared across type of exposure and journal. RESULTS: The reporting of methods in the 408 identified papers was generally poor, with basic information about recruitment of participants often absent. Reduction of selection bias was described best in the "pencil and paper" studies and worst in the genetic studies. Neuroimaging studies reported the most safeguards against information bias. Measurement of exposure was reported least well in studies determining the exposure with a biological test. CONCLUSIONS: Poor reporting of recruitment strategies threatens the validity of reported results and reduces the generalisability of studies.

Adherence therapy for people with schizophrenia. European multicentre randomised controlled trial.

BACKGROUND: There is equivocal evidence of the effectiveness of adherence therapy in improving treatment adherence and clinical outcomes for people with schizophrenia. AIMS: To evaluate the effectiveness of adherence therapy in improving quality of life for people with schizophrenia. METHOD: A 52-week, single-blind, multicentre randomised controlled trial of the effectiveness of adherence therapy. Participants were individually randomised to receive eight sessions of adherence therapy or health education. Assessments were undertaken at baseline and at 52-week follow-up. RESULTS: Adherence therapy was no more effective than health education in improving quality of life. CONCLUSIONS: This effectiveness trial provides evidence for the lack of effect of adherence therapy in people with schizophrenia with recent clinical instability, treated in ordinary clinical settings.

Persistence with polypharmacy and excessive dosing in patients with schizophrenia treated in four European countries.

The purpose of this study was to calculate the proportion of patients with schizophrenia receiving persistent antipsychotic polypharmacy and excessive dosing in four European countries; to test the hypothesis that excessive dosing and/or antipsychotic polypharmacy is associated with higher levels of psychopathology; and to establish whether use of second-generation antipsychotics is a protective or a risk factor for polypharmacy and excessive dosing. Participants with schizophrenia were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (Netherlands), and Leipzig (Germany). We defined patients persistently receiving high antipsychotic dose (i.e. excessive dosing) as those with a prescribed daily dose/defined daily dose ratio of >1.5 both at initial assessment and after 1 year of follow-up. Similarly, we defined patients persistently receiving polypharmacy as those being prescribed two or more antipsychotic drugs both at baseline and at follow-up. A sample of 375 participants with schizophrenia was analyzed. A proportion of 28% of patients persistently received high-dose antipsychotic drugs, and a proportion of 13% of patients persistently received antipsychotic polypharmacy. In the multivariate analysis, psychopathology was not a predictor of persistent polypharmacy and excessive dosing; similarly, use of second-generation antipsychotics was not associated with polypharmacy and excessive dosing; however, persistence with high antipsychotic doses was predicted by baseline use of first-generation antipsychotics and second-generation antipsychotics concurrently. Antipsychotic drug use for patients with schizophrenia is only sometimes satisfactory and offers the opportunity of improvement. Clinicians should consider that dose reduction strategies have been shown to be a feasible intervention in patients with schizophrenia.

Adherence to medication and quality of life in people with schizophrenia: results of a European multicenter study.

Quality of life is often severely impaired in people with schizophrenia, and adherence to antipsychotic medication has been consistently found to be low in this population. Although there is a considerable amount of evidence on these two variables in schizophrenia research, there is only limited knowledge on how they relate to one another. The aim of this study is to develop a meaningful model of the relationship between quality of life and adherence that includes mediating variables. A multicenter randomized controlled trial recruited 409 subjects in London, Verona, Amsterdam, and Leipzig. Baseline interviews obtained data on adherence, quality of life, and other variables. We used graphical modeling to investigate the relationships between the variables. No direct relation could be discerned between subjective quality of life and adherence to medication. Mediating variables, most importantly symptomatic impairment, global functioning, and medication side effects, were identified by the model. It can be concluded that, when aiming at the improvement of quality of life in people with schizophrenia, variables other than adherence, i.e., symptomatic impairment, global functioning, and medication side effects, should be targeted.

Do community treatment orders for mental illness reduce readmission to hospital? An epidemiological study.

BACKGROUND: It has been suggested that community treatment orders (CTOs) will prevent readmission to hospital, but controlled studies have been inconclusive. We aimed to test the hypothesis that hospital discharges made subject to CTOs are associated with a reduced risk of readmission. The use of such a measure is likely to change after its introduction as clinicians acquire familiarity with it, and we also tested the hypothesis that the characteristics of patients subject to CTOs changed over time in the first decade of their use in Victoria, Australia. METHOD: A database from Victoria, Australia (total population 4.8 million) was used. Cox proportional hazard models compared the hazard ratios of readmission to hospital before the end of the study period (1992-2000) for 16,216 discharges subject to a CTO and 112,211 not subject to a CTO. RESULTS: Community treatment orders used on discharge from a first admission to hospital were associated with a higher risk of readmission, but CTOs following subsequent admissions were associated with lower readmission risk. The risk also declined over the study period. CONCLUSIONS: The effect of using a CTO depends on the patient's history. At a population level their introduction may not reduce readmission to hospital. Their impact may change over time. DECLARATION OF INTEREST: None.

Determinants of first- and second-generation antipsychotic drug use in clinically unstable patients with schizophrenia treated in four European countries.

The present study investigated the use of antipsychotics in a sample of clinically unstable patients with schizophrenia who were recruited in four European sites. The study aimed: (i) to test whether the length of previous antipsychotic exposure was associated with the choice of antipsychotic medication; (ii) to test whether the severity of illness was associated with the use of second-generation antipsychotic agents (SGAs) or with the concomitant use of both first-generation antipsychotics (FGAs) and SGAs; and (iii) to investigate differences between study sites. Participants were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (The Netherlands) and Leipzig (Germany). Clinically unstable patients with a clinical diagnosis of schizophrenia and a research diagnosis of schizophrenia, established using the Item Group Checklist of the Schedule for Clinical Assessment in Neuropsychiatry, were enrolled. Sociodemographic and clinical data, including current antipsychotic drug therapy, psychopathology, adherence, insight, side-effects, attitudes towards medication and quality of life, were gathered. Three hundred and ninety patients were analysed in total. Almost 60% received SGAs, less than one-third FGAs, and less than 15% received both drug classes. Those receiving SGAs were younger and with a shorter length of antipsychotic drug therapy, whereas those receiving both drug classes were more often separated or widowed, unemployed and with a long history of antipsychotic drug therapy. The distribution of patients receiving FGAs, SGAs and both drug classes by illness-related variables showed that patients receiving both drug classes were more severely ill and complained of more side-effects. Using patients receiving FGAs as the reference category, multinomial logistic regression analysis showed that the length of antipsychotic treatment was negatively correlated with receiving SGAs, and that the severity of illness and being separated/widowed were positively correlated with receiving both drug classes. Compared with patients in Leipzig, patients in Amsterdam, Croydon and Verona were less frequently treated with SGAs and with combinations of both drug classes. Consistent with current clinical uncertainty with respect to what pharmacological treatment should be provided, patients with a long history of antipsychotic exposure were receiving FGAs, SGAs and combinations of both drug classes. Physicians tended to reserve polypharmacy for difficult-to-treat patients (i.e. for managing situations where, despite the lack of an evidence base, there is a pressing need to provide clinical answers).

Sex differences in the subjective tolerability of antipsychotic drugs.

In recent years, research efforts have been directed to better characterize the subjective experience of taking psychotropic drugs. This study investigated the sex difference in the subjective tolerability of antipsychotic drugs. Participants were recruited from patients under the care of psychiatric services serving geographical catchment areas in Croydon (UK), Verona (Italy), Amsterdam (Netherlands), and Leipzig (Germany). Clinically unstable patients with a clinical diagnosis of schizophrenia and a research diagnosis of schizophrenia, established using the Item Group Checklist of the Schedule for Clinical Assessment in Neuropsychiatry, were enrolled. Antipsychotic subjective tolerability was rated by means of the Liverpool University Neuroleptic Side Effect Rating Scale. During the recruitment period, 245 men and 164 women with schizophrenia were recruited. In both sexes, the most frequently reported side effects were difficulty in concentrating, tiredness, and weight gain; these side effects occurred in approximately 50% of men and in up to 70% of women. Extrapyramidal and anticholinergic reactions were reported more often by women, whereas men reported sexual problems more often. After background group differences were controlled for, sex was the strongest determinant of the subjective tolerability of antipsychotic drugs. We therefore conclude that sex differences in the subjective tolerability of antipsychotic drugs should be taken into account in the pharmacological management of patients with schizophrenia. Studies should no longer consider men and women as a homogeneous group, given that the subjective tolerability of antipsychotic drugs substantially differs between sexes.

Perceived coercion at admission to psychiatric hospital and engagement with follow-up--a cohort study.

BACKGROUND: Measures of perceived coercion at psychiatric hospital admission have been developed. We aimed to investigate predictors of perceived coercion in subjects admitted to psychiatric hospital in the UK, and to test the hypothesis that high perceived coercion at admission predicts poor engagement with community follow-up. METHOD: A cohort of consecutively admitted subjects were interviewed at admission and before discharge, and were followed prospectively for 10 months. Service use and compliance with care were rated from case notes and by clinicians. RESULTS: One hundred interviews were obtained from 118 consecutive admissions (85%). Compulsory admission was strongly associated with perceived coercion, but one-third of voluntary patients felt highly coerced, and two-thirds were not certain they were free to leave hospital. Greater age, less insight, and non-white ethnicity were associated with high perceived coercion. Perceived coercion did not predict engagement with follow-up. CONCLUSIONS: Services recognise provision of care in the least restrictive setting as a key objective. Perceived coercion should be regarded as an important outcome measure in service evaluation.

Information, consent and perceived coercion: patients' perspectives on electroconvulsive therapy.

BACKGROUND: Electroconvulsive therapy (ECT) is a procedure that attracts special safeguards under common law for voluntary patients and under both current and proposed mental health legislation, for those receiving compulsory treatment. AIMS: To review patients' views on issues of information, consent and perceived coercion. METHOD: Seventeen papers and reports were identified that dealt with patients' views on information and consent in relation to ECT; 134 'testimonies' or first-hand accounts were identified. The papers and reports were subjected to a descriptive systematic review. The testimony data were analysed qualitatively. RESULTS: Approximately half the patients reported that they had received sufficient information about ECT and side-effects. Approximately a third did not feel they had freely consented to ECT even when they had signed a consent form. Clinician-led research evaluates these findings to mean that patients trust their doctors, whereas user-led work evaluates similar findings as showing inadequacies in informed consent. CONCLUSION: Neither current nor proposed safeguards for patients are sufficient to ensure informed consent with respect to ECT, at least in England and Wales.

Patients' perspectives on electroconvulsive therapy: systematic review.

OBJECTIVE: To ascertain patients' views on the benefits of and possible memory loss from electroconvulsive therapy. DESIGN: Descriptive systematic review. DATA SOURCES: Psychinfo, Medline, Web of Science, and Social Science Citation Index databases, and bibliographies. STUDY SELECTION: Articles with patients' views after treatment with electroconvulsive therapy. DATA EXTRACTION: 26 studies carried out by clinicians and nine reports of work undertaken by patients or with the collaboration of patients were identified; 16 studies investigated the perceived benefit of electroconvulsive therapy and seven met criteria for investigating memory loss. DATA SYNTHESIS: The studies showed heterogeneity. The methods used were associated with levels of perceived benefit. At least one third of patients reported persistent memory loss. CONCLUSIONS: The current statement for patients from the Royal College of Psychiatrists that over 80% of patients are satisfied with electroconvulsive therapy and that memory loss is not clinically important is unfounded.

Poverty, poor services, and compulsory psychiatric admission in England.

BACKGROUND: Compulsory admission is a central feature of psychiatric systems internationally but the factors determining its use within different legal systems are not understood. Numbers of compulsory psychiatric admissions vary widely between areas in England. We examined the hypothesis that variation in rates of detention is related to social deprivation and also to the functioning of local mental health services. METHODS: Rates of detention under sections 2 and 3 of the Mental Health Act (1983) in 1998/9 were obtained in 34 mental health sectors in eight Trusts in England. Measures of socio-economic deprivation and measures of service function were used to conduct an ecological analysis. RESULTS: Compulsory admission is associated with measures of deprivation but there is unexplained variation. The range in rates is higher than allowed for by the resource allocation formula. Some indicators of service quality are independently associated with rates of detention. CONCLUSIONS: Variation in detention rates and its relation to service function need further explanation if the use of compulsion is to be reduced.