Adolescent experience of radically open dialectical behaviour therapy: a qualitative study.

BACKGROUND: Radically Open Dialectical Behaviour Therapy (RO DBT) is a novel transdiagnostic treatment that targets 'maladaptive overcontrol'; a transdiagnostic cluster of traits associated with excessive emotional and behavioural inhibitory control. Outcomes are promising for adults with a range of psychiatric disorders. No study to date has explored the adolescent experience of RO DBT. METHODS: Of the 25 eligible adolescents who received RO DBT between March 2015 and April 2017, 15 (14-17 years) consented and completed a semi-structured interview about their experience of treatment within 1 month of discharge. Interviews were recorded and then transcribed manually. Free text responses were analysed using reflexive thematic analysis. RESULTS: The majority (n = 13) had a primary diagnosis of anorexia nervosa, although comorbidity was the norm, with 80.0% having two or more predicted comorbid psychiatric diagnoses. All had received some prior psychological treatment. Four themes were identified from analysis of transcripts: 1) Broadening Horizons, 2) Building Connections, 3) Flexibility, 4) Information Overload. Generally, RO DBT was perceived as helpful in both content and process. The focus on social and broader well-being, rather than specific mental health symptoms, was considered beneficial by many. Adolescents appreciated the group-based format of skills classes and reported benefiting from learning and practicing skills each week. The fourth theme, Information Overload, highlighted that for some, the amount of content felt overwhelming and that it was hard to remember and digest all the information, suggesting that adaptations, or simplifications, may be required to ensure accessibility for adolescents. CONCLUSIONS: RO DBT is perceived as a relevant and beneficial new treatment for adolescents with maladaptive overcontrol. The broad treatment focus is perceived as unique and of particular benefit. It is reported to help with general and social functioning and foster cognitive and behavioural flexibility. Nevertheless, the amount and complexity of material was felt to be very large by some and may suggest the need for modified adolescent-specific materials.

Radically open dialectical behaviour therapy adapted for adolescents: a case series.

BACKGROUND: Overcontrol is a transdiagnostic cluster of traits associated with excessive psychological, behavioural and social inhibitory control. It is associated with psychiatric diagnoses of depression, restrictive eating disorders and/or obsessive-compulsive personality disorder. Radically Open Dialectical Behaviour Therapy is a transdiagnostic treatment for maladaptive overcontrol. This case series evaluates an adolescent adaption (RO-A) for a transdiagnostic group of adolescents identified as overcontrolled. METHODS: Twenty-eight adolescents were consecutively referred for RO-A from two different National and Specialist Child and Adolescent Mental Health Services between June 2017 and February 2020. Baseline self-report measures assessed overcontrol characteristics, relationship and attachment quality and mental health symptoms of depression and eating disorders, which were repeated at discharge. RESULTS: Adolescents in this case series reported high rates of depression (78.6%), self-harm (64.3%) and eating disorders (78.6%). Most (85.7%) had two or more mental health diagnoses and all had previous mental health treatments before starting RO-A. The mean number of RO-A sessions attended was 18 group-based skills classes and 21 individual sessions over a mean period of 34 weeks. Significant improvements with medium and large effect sizes were reported in cognitive flexibility (d = 1.63), risk aversion (d = 1.17), increased reward processing (d = .79) and reduced suppression of emotional expression (d = .72). Adolescents also reported feeling less socially withdrawn (d = .97), more connected to others (d = 1.03), as well as more confident (d = 1.10) and comfortable (d = .85) in attachment relationships. Symptoms of depression (d = .71), eating disorders (d = 1.06) and rates of self-harm (V = .39) also significantly improved. Exploratory correlation analyses suggest improvements in overcontrol are moderately to strongly correlated with improvements in symptoms of depression and eating disorders. CONCLUSIONS: This case series provides preliminary data that RO-A may be an effective new treatment for adolescents with overcontrol and moderate to severe mental health disorders like depression and eating disorders. RO-A led to improved management of overcontrol, improved relationship quality and reduced mental health symptoms. Further evaluation is indicated by this case series, particularly for underweight young people with eating disorders. More rigorous testing of the model is required as conclusions are only tentative due to the small sample size and methodological limitations.

Development of a measure of caregiver burden in paediatric chronic kidney disease: The Paediatric Renal Caregiver Burden Scale.

To inform the development of a measure of caregiver burden for carers of children with chronic kidney disease, interviews were conducted with 16 caregivers and 10 renal healthcare professionals. A pool of 97 items generated from interviews was reduced to 60 items following review. A piloting exercise provided evidence for the usability, readability and relevance of items and informed further adaptations resulting in the 51-item Paediatric Renal Caregiver Burden Scale. Further to assessment of its psychometric properties, it is hoped that that the Paediatric Renal Caregiver Burden Scale will serve as a useful measure of caregiver burden in paediatric chronic kidney disease.

Profiling patient attitudes to phosphate binding medication: a route to personalising treatment and adherence support.

OBJECTIVE: Nonadherence to phosphate binding medication (PBM) compromises the efficacy of treatment for chronic kidney disease, but its causes are poorly understood. This study sought to explore patient attitudes towards PBM and to evaluate the utility of the necessity-concerns framework for understanding adherence to PBM. DESIGN: A sample of 221 dialysis patients currently prescribed PBM were surveyed from eight UK renal units. MAIN OUTCOME MEASURES: Demographic data and clinical information, alongside the Beliefs about Medicines Questionnaire and the medication adherence report scale were reported. RESULTS: Low adherence to PBM was predicted by reduced beliefs in personal need for PBM (OR = .34; 95% CI: .14-.83; p < .05), and increased concerns about PBM (OR = 3.17; 95% CI: 1.87-5.37; p < .001). Patients were categorised into attitudinal groups based on their beliefs about PBM and being 'skeptical' of PBM (low necessity beliefs and high concerns) was most associated with low adherence. CONCLUSION: Strategies to improve adherence to PBM should aim to elicit and address patients' beliefs about their personal need for PBM and their concerns about this medication.

Understanding patients' adherence-related beliefs about medicines prescribed for long-term conditions: a meta-analytic review of the Necessity-Concerns Framework.

BACKGROUND: Patients' beliefs about treatment influence treatment engagement and adherence. The Necessity-Concerns Framework postulates that adherence is influenced by implicit judgements of personal need for the treatment (necessity beliefs) and concerns about the potential adverse consequences of taking it. OBJECTIVE: To assess the utility of the NCF in explaining nonadherence to prescribed medicines. DATA SOURCES: We searched EMBASE, Medline, PsycInfo, CDSR/DARE/CCT and CINAHL from January 1999 to April 2013 and handsearched reference sections from relevant articles. STUDY ELIGIBILITY CRITERIA: Studies using the Beliefs about Medicines Questionnaire (BMQ) to examine perceptions of personal necessity for medication and concerns about potential adverse effects, in relation to a measure of adherence to medication. PARTICIPANTS: Patients with long-term conditions. STUDY APPRAISAL AND SYNTHESIS METHODS: Systematic review and meta-analysis of methodological quality was assessed by two independent reviewers. We pooled odds ratios for adherence using random effects models. RESULTS: We identified 3777 studies, of which 94 (N = 25,072) fulfilled the inclusion criteria. Across studies, higher adherence was associated with stronger perceptions of necessity of treatment, OR = 1.742, 95% CI [1.569, 1.934], p<0.0001, and fewer Concerns about treatment, OR = 0.504, 95% CI: [0.450, 0.564], p<0.0001. These relationships remained significant when data were stratified by study size, the country in which the research was conducted and the type of adherence measure used. LIMITATIONS: Few prospective longitudinal studies using objective adherence measures were identified. CONCLUSIONS: The Necessity-Concerns Framework is a useful conceptual model for understanding patients' perspectives on prescribed medicines. Taking account of patients' necessity beliefs and concerns could enhance the quality of prescribing by helping clinicians to engage patients in treatment decisions and support optimal adherence to appropriate prescriptions.

Understanding medication non-adherence in bipolar disorders using a Necessity-Concerns Framework.

BACKGROUND: Medication non-adherence is a major problem in patients with severe mental disorders and is associated with poor clinical outcomes and high resource utilization. This study examined the utility of the Necessity-Concerns Framework for understanding patient attitudes towards and levels of adherence with medications prescribed for bipolar disorders. METHOD: A convenience sample of 223 individuals currently prescribed medication for bipolar disorders, recruited by advertisement in a Manic Depression Fellowship newsletter, completed the Beliefs about Medication Questionnaire and the Medication Adherence Report Scale. RESULTS: Low adherence was reported by 30% (n=64) and was predicted by greater doubts about personal need for treatment (OR=.50; 95% CI: .31-.82) and stronger concerns about potential negative effects (OR=2.00; 95% CI: 1.20-3.34). These predictors were independent of current mood state, illness and demographic characteristics. LIMITATIONS: Participants were a potentially biased sample of volunteers who had been recruited through a patient organisation newsletter. However, clinical characteristics and adherence rates in this study were similar to those reported in other studies conducted in Europe and the USA. CONCLUSIONS: The Necessity-Concerns Framework is a useful theoretical model for understanding key attitudes towards medication in bipolar disorders. Interventions to facilitate adherence should elicit and address patients' beliefs about medication.

Patients' attitudes to medicines and adherence to maintenance treatment in inflammatory bowel disease.

BACKGROUND: Nonadherence has been reported in over 40% of patients taking maintenance therapies (MT) for inflammatory bowel disease (IBD). Studies in other illness groups have shown that nonadherence is related to negative attitudes to treatment. The aim of this study was to assess patients' attitudes to MT for IBD (beliefs about personal need for MT and potential adverse effects) and to identify whether such beliefs are associated with adherence to MT. METHODS: A cross-sectional survey was conducted in which 1871 members of the National Association for Colitis and Crohn's Disease (NACC) completed validated questionnaires assessing beliefs about MT and adherence to MT. RESULTS: Low adherence to MT was reported by 29% of participants and was associated with doubts about personal need for MT (odds ratio [OR] = 0.56; 95% confidence interval [CI]: 0.48-0.64; P < 0.001) and concerns about potential adverse effects (OR = 1.66; 95% CI: 1.42-1.94; P < 0.001). Attitudinal analysis showed that while almost half (48%) of the participants were "accepting" of MT (high necessity, low concerns), a large proportion of the sample (42%) were "ambivalent" about MT (high necessity, high concerns), 6% were "sceptical" (low necessity, high concerns) and 4% were "indifferent" (low necessity, low concerns). Compared to those who were "accepting" of MT, participants in all 3 other attitudinal groups were significantly more likely to be nonadherent. CONCLUSIONS: The way in which patients judge their personal need for MT relative to their concerns about MT can be a significant barrier to adherence. Interventions to facilitate optimal adherence to MT for IBD should address such perceptual barriers.

Adherence to medication in bipolar disorder: a qualitative study exploring the role of patients' beliefs about the condition and its treatment.

OBJECTIVES: Patients' perceptions of illness and treatment have been found to predict adherence to medication in many chronic conditions. This has not yet been fully explored in bipolar disorder (BD). The aim was to use a qualitative methodology to explore in depth the beliefs about BD and its treatment that are associated with adherence to medication prescribed for BD. METHODS: Sixteen adults prescribed prophylactic treatment for BD completed semi-structured interviews about their perceptions of BD and its treatment and their adherence to medication. Interviews were recorded and transcribed verbatim. Two researchers identified perceptions associated with non-adherence in the transcripts. RESULTS: Thirteen participants (81%) reported some degree of intentional or unintentional medication non-adherence. Intentional non-adherence was associated with patients' concerns about the prescribed medication, arising from the experience of side effects, but also from beliefs that regular use could lead to adverse effects in the future. Intentional non-adherence was also associated with doubts about the personal need for medication, which were related to perceptions of BD (e.g., not accepting diagnosis, believing the condition is not controllable, believing it is not a chronic condition). CONCLUSIONS: This study has identified some of the salient beliefs about BD and its treatment that should be elicited and addressed in interventions to facilitate adherence to medication. Further quantitative work is justified to explore the utility of this approach in the development of interventions.

Patients' perceptions of information received about medication prescribed for bipolar disorder: implications for informed choice.

BACKGROUND: Previous research suggests that patients are dissatisfied with information provided about medication prescribed for mental illness, but has not identified which aspects of information provision are unsatisfactory. METHODS: 223 members of the Manic Depression Fellowship (MDF) completed the Satisfaction with Information about Medicines Scale (SIMS), a validated measure of patients' satisfaction with various aspects of information provision. RESULTS: Patients reported highest dissatisfaction with information about potential problems associated with medication; over 60% of participants reported dissatisfaction with information about the risks of side effects and whether the medication would affect their sex lives. Participants were significantly less satisfied with information about potential problems associated with their medication than people prescribed medication for HIV in a previously reported study (p<.01). Those reporting low adherence to medication had significantly lower satisfaction with information scores than those reporting high adherence (p<.05). LIMITATIONS: The sample could be prone to selection bias; participants were members of an organisation for people affected by bipolar disorder, whilst the comparator group was a NHS HIV clinic sample. Furthermore, the objective amount and type of information provided was not assessed, therefore the cause of patients' dissatisfaction is not known. CONCLUSIONS: Perceived satisfaction with information is low, particularly in relation to possible drug side-effects. Health practitioners need to elicit individuals' information requirements and tailor information to meet their needs, in order to facilitate informed choice and adherence to treatment. Moreover, they need to provide information in a manner appropriate for a patient's cognitive functioning at different illness phases.