Conocimiento del tratamiento en esquizofrenia y trastorno esquizoafectivo y su relación con la no adherencia / Knowledge of the treatment in schizophrenia and schizoaffective disorder and its relationship with nonadherence

Introducción. El conocimiento del tratamiento ha sidoescasamente estudiado en pacientes con psicosis, a pesar de su potencial importancia para la adherencia. Evaluamos la posible asociación entre el conocimiento del tratamiento y la no adherencia, no adherencia no intencional (NANI) y no adherencia intencional (NAI). Metodología. Se incluyeron 106 pacientes con diagnóstico de esquizofrenia o trastorno esquizoafectivo que ingresaron consecutivamente. Las evaluaciones se realizaron durante la hospitalización y a los seis meses de seguimiento. Se incluyeron variables sociodemográficas, clínicas, psicopatológicas y relacionadas con el tratamiento. La adherencia se definió como la concurrencia de adherencia al tratamiento antipsicótico y adherencia al seguimiento ambulatorio durante ese periodo de seis meses. Establecimos dos subtipos de no adherencia dependiendo del motivo principal de no adherencia: NANI y NAI. Resultados. El 45,3% de los pacientes mostraron un inadecuado conocimiento del tratamiento. Los pacientes adherentes, comparados con los no adherentes, no mostraron diferencias en el conocimiento del tratamiento (mediana 77 vs. 77, respectivamente; p = 0,232). Sin embargo, los pacientes NANI presentaron peor conocimiento del tratamiento comparados con los pacientes adherentes (mediana 62 vs. 77 respectivamente; p < 0,001), mientras que los pacientes NAI presentaron mejor conocimiento del tratamiento comparados con los pacientes adherentes (mediana 86 vs. 77, respectivamente; p = 0,026). Conclusión. Un alto porcentaje de los pacientes con esquizofrenia y trastorno esquizoafectivo no tienen un adecuado conocimiento del tratamiento. Además, nuestros resultados sugieren que un inadecuado conocimiento del tratamiento puede contribuir a la no adherencia en pacientescon no adherencia no intencional. (AU)

Background and objectives. Despite its potential importance for adherence, knowledge of the treatment has been little studied in patients with psychosis. We performed this study to assess the possible association between knowledge of the treatment and nonadherence, unintentional nonadherence (UNA) and intentional nonadherence (INA). Methods. We assessed 106 consecutively admitted patients diagnosed with schizophrenia or schizoaffective disorder. Evaluations were carried out during hospitalization and after six-months of follow-up. This included sociodemographic, clinical, psychopathologic variables and those related to treatment. Adherence was interpreted as the concurrence of adherence to antipsychotic treatment and adherence to outpatient follow-up over the course of the six-month period. We established two subtypes according to the main reason for nonadherence: unintentional and intentional nonadherence. Results. Inadequate knowledge of the treatment was detected in 45.3% of patients. Adherent patients, as compared to nonadherent patients, showed no difference regarding knowledge of the treatment (median 77 vs. 77, respectively; p = 0.232). Nevertheless, UNA patients showed worse knowledge of the treatment as compared to adherent patients (median 62 vs. 77 respectively; p < 0.001), whereas INA patients showed better knowledge of the treatment as compared to adherent patients (median 86 vs. 77, respectively; p = 0.026). Conclusions. A large number of patients with schizophrenia or schizoaffective disorder did not have an appropriate knowledge of their treatment. More importantly, our results suggest that inadequate knowledge of the treatment may contribute to nonadherence in patients with unintentional nonadherence. (AU)

Prevalence and Patient-Level Correlates of Intentional Non-Adherence to Immunosuppressive Medication After Heart-Transplantation-Findings From the International BRIGHT Study.

After heart transplantation (HTx), non-adherence to immunosuppressants (IS) is associated with poor outcomes; however, intentional non-adherence (INA) is poorly understood regarding its international variability in prevalence, contributing factors and impact on outcomes. We investigated (1) the prevalence and international variability of INA, (2) patient-level correlates of INA, and (3) relation of INA with clinical outcomes. Secondary analysis of data from the BRIGHT study-an international multi-center, cross-sectional survey examining multi-level factors of adherence in 1,397 adult HTx recipients. INA during the implementation phase, i.e., drug holiday and dose alteration, was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale© (BAASIS©). Descriptive and inferential analysis was performed with data retrieved through patient interview, patient self-report and in clinical records. INA prevalence was 3.3% (n = 46/1,397)-drug holidays: 1.7% (n = 24); dose alteration: 1.4% (n = 20); both: 0.1% (n = 2). University-level education (OR = 2.46, CI = 1.04-5.83), insurance not covering IS costs (OR = 2.21, CI = 1.01-4.87) and barriers (OR = 4.90, CI = 2.73-8.80) were significantly associated with INA; however, clinical outcomes were not. Compared to other single-center studies, this sample's INA prevalence was low. More than accessibility or financial concerns, our analyses identified patient-level barriers as INA drivers. Addressing patients' IS-related barriers, should decrease INA.

Substance Use-Related Intentional Nonadherence to Antiretroviral Therapy Among Young Adults Living with HIV.

Antiretroviral therapy (ART) reduces HIV disease burden, increases life expectancy, and prevents HIV transmission. Previous research suggests that believing that it is harmful to take ART when using substances (i.e., interactive toxicity beliefs) leads to intentional ART nonadherence; however, these associations have not been investigated among younger adults living with HIV and have not been linked to clinical outcomes. We examined the associations among interactive toxicity beliefs, intentional nonadherence, and HIV clinical outcomes in young adults living with HIV. People living with HIV younger than the age of 36 years who tested positive for at least one substance use biomarker (N = 406) completed a 1-month pretrial run-in study that included computerized interviews, substance use biomarkers, HIV viral load, and unannounced pill counts for ART adherence. Analyses compared three HIV clinical outcome groups: (1) HIV viral unsuppressed, (2) HIV viral suppressed and ART nonadherent, and (3) HIV viral suppressed and ART adherent, on substance use, interactive toxicity beliefs, and substance use-related intentional ART nonadherence. Results showed that a majority of participants reported intentional nonadherence. Participants with unsuppressed HIV reported greater interactive toxicity beliefs and intentional nonadherence. We conclude that intentional nonadherence adds to the detrimental impacts of substance use on ART adherence and interactive toxicity beliefs that foster these behaviors may be amenable to interventions.

Patients' Characterization of Medication, Emotions, and Incongruent Perceptions around Adherence.

Medication nonadherence is prevalent among patients with chronic diseases. Previous research focused on patients' beliefs in medication or illness and applied risk-benefit analyses when reasoning their behavior. This qualitative study examined rheumatoid arthritis (RA) patients' perceptions and feelings toward medication in parallel with attitudes about their own adherence. We conducted four 90-min focus groups and seven 60-min interviews with a diverse sample of RA patients (n = 27). Discussions covered dilemmas encountered, emotions, and thought process concerning medication, and included application of projective techniques. Transcripts were analyzed in NVivo-12 using a thematic coding framework through multiple rounds of deduction and categorization. Three themes emerged, each with mixed sentiments. (1) Ambivalent feelings toward medication: participants experienced internal conflicts as their appreciation of drugs for relief contradicted worries about side effects or "toxicity" and desire to not identify as sick, portraying medications as "best friend" and "evil". (2) Struggles in taking medication: participants "hated" the burden of managing regimen and resented the reliance and embarrassment. (3) Attitudes and behavior around adherence: most participants self-reported high adherence yet also described frequently self-adjusting medications, displaying perception-action incongruency. Some expressed nervousness and resistance while others felt empowered when modifying dosage, which might have motivated or helped them self-justify nonadherence. Only a few who deviated from prescription discussed it with their clinicians though most participants expressed the desire to do so; open communication with providers reinforced a sense of confidence and control of their own health. Promoting personalized care with shared decision-making that empowers and supports patients in managing their long-term treatment could encourage adherence and improve overall health outcome.

Factors Associated with Medication Non-Adherence among Patients with Lifestyle-Related Non-Communicable Diseases.

This cross-sectional study explored the association between medication non-adherence and its factors in patients with non-communicable diseases (NCDs) using an online structured questionnaire emailed to 30,000 people (aged over 20 years who lived in Japan at the time of the survey). The questions concerned respondents' characteristics, medication non-adherence, health beliefs, lifestyles, and trouble taking medication. Factors related to non-adherence were analyzed among patients with lifestyle-related NCDs categorized into two age groups: 20-59, and >60 years. Unintentional (p < 0.001) and intentional (p < 0.001) non-adherence were more common among patients aged 20-59 than in older adults. NCD patients aged 20-59 experienced significantly more trouble taking medication than older adults. Multiple regression analysis showed that for patients aged 20-59 with NCDs, unintentional non-adherence was significantly and positively associated with current smoking habits (ß = 0.280, p < 0.001), while intentional non-adherence was significantly and positively associated with alcohol consumption (ß = 0.147, p = 0.020) and current smoking habits (ß = 0.172, p = 0.007). In patients aged 20-59, unhealthy eating habits (ß = -0.136, p = 0.034) and lack of exercise (ß = -0.151, p = 0.020) were negatively associated with intentional non-adherence. In conclusion, factors affecting medication non-adherence in patients with lifestyle-related diseases are related to health awareness, lifestyle, and medication barriers.

Forgoing antiretroviral therapy to evade stigma among people living with HIV, Cape Town, South Africa.

Stigma impedes HIV treatment in multiple ways, including diminished engagement in care, refusing ART, and concealing ART to evade stigma. This study disentangled the degree to which intentionally not taking ART to evade stigma influences overall non-adherence to ART. Patients receiving ART at a community clinic in Cape Town, South Africa (N = 288) completed confidential surveys of demographic and health characteristics, stigma-avoidance non-adherence, and non-stigma-related predictors of non-adherence. Results found nearly half of participants (48%) had forgone taking their ART in social settings. Hierarchically structured regression models showed that alcohol use, medication concerns, and internalized HIV stigma significantly predicted ART non-adherence, accounting for 9.9% of the variance. Stigma-avoidance non-adherence explained an additional 2.6% of the variance in ART non-adherence. The current findings extend previous research to show that stigma-avoidance independently contributes to ART non-adherence, including over and above depression and alcohol use.

Testing the hypothesis of subtypes of nonadherence in schizophrenia and schizoaffective disorder: A prospective study.

BACKGROUND: Nonadherence is a major problem in the treatment of psychotic disorders. It has been hypothesized that nonadherent patients with schizophrenia are not a homogeneous population and subtypes of nonadherence might exist, but this hypothesis has not been specifically tested. AIM: To test the hypothesis of subtypes of nonadherence in schizophrenia and schizoaffective disorder. METHODS: This prospective study included 110 consecutively admitted patients diagnosed with schizophrenia or schizoaffective disorder. Assessments were performed at baseline and at 6 mo follow-up after discharge. Sociodemographic, clinical, psychopathological and treatment-related variables were evaluated. Adherence was defined as the concurrence of adherence to antipsychotic treatment and outpatient follow-up during the six-month period. Adherence to antipsychotic treatment was defined as the concurrence of objective and subjective adherence. Sixty-four patients (58%) fulfilled nonadherence criteria at the end of the follow-up period and were categorized according to their subtype of nonadherence. RESULTS: In nonadherent patients (n = 64), 32 (50%) fulfilled criteria of intentional nonadherence, and 32 (50%) of unintentional nonadherence (UNA). Unintentional nonadherent patients, as compared to intentional nonadherent patients, are characterized by older age, lower educational level, worse cognitive and negative symptoms, greater severity, worse knowledge of their treatment regimen, greater prevalence of supervision of the treatment, lower number of prior hospitalizations and greater use of nonpsychiatric treatment, anticholinergics and hypnotics. Low educational level (OR = 26.1; 95%CI: 2.819-241), worse treatment knowledge at six months (OR per unit = 0.904; 95%CI: 0.853-0.957) and nonpsychiatric treatment at six months (OR = 15.8; 95%CI: 1.790-139) were independently associated to UNA. CONCLUSION: Differentiated subtypes of nonadherence according to intentionality seem to exist in patients with schizophrenia and schizoaffective disorder. Our findings suggest the need for differentiated approach, both in future research and in clinical practice.

Effect of health professional intervention on adherence to statin use according to the cause of patient non-adherence.

Background Non-adherence is a problem that particularly affects those with chronic diseases. Studying causes for not following the treatment is necessary to choose the best intervention to improve non-adherence. Objective Analyze how the intentionality of non-adherence modulates the effects of professional intervention in patients with hypercholesterolemia. Setting: Community pharmacies and primary care centres in Spain. Methods A 6-month randomized controlled trial was conducted in 46 community pharmacies and 50 primary care centres in Spain. Adherence to statin therapy was measured with the Morisky-Green-Levine test. Non-adherence was classified based on the intentionality. Results 746 Patients were recruited for the study (465 non-adherent and 281 adherent). Of those, 237 were randomly assigned to the intervention group and 228 to the non-intervention group. The 56.5% of non-adherent patients were classified as unintentional non-adherents and 43.5% as intentional non-adherents. More patients in the intervention group finished being adherent compared with the non-intervention group (+ 17.2% for intentional non-adherents and + 27.4% for unintentional non-adherence). The percentage of patients in the intervention group who completed the study as adherent was higher among those who previously had unintentional non-adherence (66.4%) compared to those with intentional non- adherence (55.3%) (p < 0.001). Conclusion Intervention provided to patients with unintentional non-adherence was more effective than intervention provided to patients with intentional non- adherence.

Alcohol-Related Intentional Antiretroviral Nonadherence among People Living with HIV: Test of an Interactive Toxicity Beliefs Process Model.

Beliefs that it is harmful to mix medications with alcohol (ie, interactive toxicity beliefs) are a known source of intentional antiretroviral therapy (ART) nonadherence. This study examined a serial process model of alcohol-ART interactive toxicity beliefs, alcohol-ART avoidance behaviors, and ART adherence in the association between alcohol use and HIV viral load. Participants were 198 patients receiving ART from a community clinic in the southeastern United States; 125 reported current alcohol use. Results showed that current alcohol use was associated with detectable HIV viral load, partially accounted for by alcohol-ART interactive toxicity beliefs, alcohol-ART avoidance behaviors, and ART adherence. There was a significant indirect effect of the serial chain of interactive toxicity beliefs-avoidance behaviors-adherence, indicating the 3 intermediating variables partially accounted for the relationship between alcohol use and HIV viral load. Addressing alcohol use as a barrier to ART adherence requires multipronged approaches that address intentional nonadherence.

The Prevalence of Nonadherence in Patients With Resistant Hypertension: A Systematic Review Protocol.

BACKGROUND: Resistant hypertension, usually defined as blood pressure remaining above goal despite the concurrent use of 3 or more antihypertensive agents of different classes, is common (about 10% prevalence) and known to be a risk factor for cardiovascular events. These patients also undergo more screening intensity for secondary hypertension. However, not all patients with apparent treatment-resistant hypertension have true resistant hypertension, with some of them being nonadherent to prescribed pharmacotherapy. The prevalence of nonadherence varies from about 5% to 80% in the published literature. However, the relative contributions of intentional and nonintentional nonadherence are not well described. Nonintentional nonadherence refers to occasional forgetfulness and/or carelessness and can sometimes be related to an inability to follow instructions, because of either cognitive or physical limitations. Intentional nonadherence refers to an active process in which a patient may choose to alter the prescribed medication regimen by discontinuing medications, skipping doses, or modifying doses or dosing intervals. OBJECTIVE: Our objective is to establish the overall prevalence of nonadherence in the apparent treatment-resistant hypertension population and evaluate the relative contributions of nonintentional and intentional nonadherence subtypes. DESIGN: We will conduct a systematic review and meta-analysis. SETTING: We will include observational studies and randomized controlled trials where adherence to antihypertensive medications is measured using a test of adherence, either direct or indirect. PATIENTS: We will include adult human participants aged 18 years or older with a diagnosis of resistant hypertension. MEASUREMENTS: Data extracted from individual studies will include title, first author, design, country, publication year, funding body, method of assessing adherence to antihypertensive medication, prevalence of medication nonadherence, definition of resistant hypertension, sample size, sex, mean age, and coexistent comorbidities. METHODS: A librarian will search the databases Medline, EMBASE, Cochrane, CINAHL, and Web of Science for studies meeting criteria for inclusion. Two reviewers will independently screen the titles and abstracts retrieved and assess the methodological quality of eligible full-text articles using the Cochrane Risk of Bias tool for clinical trials and the Newcastle-Ottawa Scale for observational studies. Summary estimates of prevalence will be generated using pooled analysis using the random-effects method. Subgroup analyses, sensitivity analyses, and evaluation of publication bias will also be performed. RESULTS: The outcomes of interest are the pooled prevalence of nonadherence to antihypertensive medication in apparent treatment-resistant hypertension and the prevalence of nonadherence based on different methods of assessing nonadherence (indirect vs direct), which will allow us to estimate the relative proportion of unintentional and intentional nonadherence subtypes in the overall phenomenon of medication nonadherence. LIMITATIONS: Possible limitations of this study include the finding of severe heterogeneity, the limitations of the literature search, publication bias, and the lack of granular data in the published studies for a study-level meta-analysis. CONCLUSIONS: This systematic review will provide a synthesis of current evidence on the prevalence of medication nonadherence in apparent treatment-resistant hypertension and on the relative contributions of nonintentional and intentional nonadherence subtypes. These findings will provide clinicians with a better understanding of the factors underlying treatment-resistant hypertension and will serve as a strong research base to guide future research on interventions to address medication nonadherence as well as the nonintentional and intentional subtypes. TRIAL REGISTRATION: This protocol has been registered with PROSPERO. We will add registration details once available.

CONTEXTE: On définit généralement l'hypertension réfractaire comme une valeur de pression artérielle qui demeure au-dessus de la valeur cible, et ce, malgré l'administration concomitante d'au moins trois agents antihypertenseurs de classes différentes. L'hypertension réfractaire est fréquente (prévalence d'environ 10 %) et constitue un facteur de risque d'événements cardiovasculaires. Les patients atteints d'hypertension réfractaire font également l'objet d'un dépistage plus intensif de l'hypertension secondaire. Cependant, tous les cas apparents d'hypertension résistante au traitement ne constituent pas nécessairement des cas d'hypertension réfractaire. Certains résultent plutôt d'une inobservance de la pharmacothérapie prescrite. La littérature rapporte une prévalence d'environ 5 à 80 % de l'inobservance du traitement, mais les contributions relatives de l'inobservance intentionnelle et non intentionnelle ne sont pas clairement établies. L'inobservance non intentionnelle fait référence aux oublis occasionnels ou à la négligence, qui peuvent être liés à l'incapacité de suivre des instructions en raison de limitations physiques ou cognitives. L'inobservance intentionnelle désigne quant à elle un processus actif où le patient choisit consciemment de modifier la posologie de sa médication, soit en interrompant le traitement, en sautant des doses ou en modifiant les doses ou les intervalles posologiques. OBJECTIFS: Nous souhaitons mesurer la prévalence globale de l'inobservance au traitement parmi les cas apparents d'hypertension réfractaire et établir la contribution relative des sous-types intentionnel et non intentionnel d'inobservance. TYPE D'ÉTUDE: Nous procéderons à une revue systématique et à une méta-analyse de la documentation pertinente. CADRE: L'étude inclura les études observationnelles et les essais contrôlés à répartition aléatoire traitant d'une mesure de l'observance du traitement antihypertenseur au moyen d'un test d'observance direct ou indirect. SUJETS: Seront inclus tous les patients adultes ayant reçu un diagnostic d'hypertension réfractaire. MESURES: Les données suivantes seront extraites de chaque étude : le titre de l'article, le nom de l'auteur principal, la méthodologie et le lieu de l'étude, l'année de publication, l'organisme ayant financé les travaux, la méthode employée pour la mesure de l'observance, la prévalence de l'inobservance, la définition d'hypertension réfractaire, la taille de l'échantillon, ainsi que le sexe, l'âge moyen et les comorbidités des patients. MÉTHODOLOGIE: Un bibliothécaire fera une présélection des études répondant aux critères d'inclusion dans les bases de données Medline, EMBASE, Cochrane, CINAHL et Web of Science. Les titres et résumés des articles retenus seront révisés de façon indépendante par deux examinateurs qui évalueront également la qualité méthodologique des articles complets à l'aide de l'outil Cochrane sur le risque de biais (essais cliniques) et de l'échelle de Newcastle-Ottawa (études observationnelles). Des estimations sommaires de la prévalence seront générées par l'analyse de l'ensemble des données par une méthode à effets aléatoires. Nous procéderons également à des analyses de sous-groupes, à des analyses de sensibilité, de même qu'à l'évaluation des biais de publication. RÉSULTATS: Le principal résultat attendu est la combinaison de la prévalence de l'inobservance du traitement antihypertenseur dans les cas d'hypertension réfractaire apparente et de la prévalence de l'inobservance selon la méthode employée pour la mesurer (indirecte ou directe). Ce résultat nous permettra d'estimer la proportion des sous-types (inobservance intentionnelle et non intentionnelle) dans l'ensemble des cas répertoriés d'inobservance au traitement. LIMITES: Les résultats pourraient être limités par une importante hétérogénéité, des facteurs limitant la recherche documentaire, des biais de publication et le manque de données agrégées dans les études publiées pour procéder à une méta-analyse au niveau de l'étude. CONCLUSION: Cette revue systématique constituera une synthèse des données probantes sur la prévalence de l'inobservance au traitement dans les cas apparents d'hypertension réfractaire et sur les contributions relatives des sous-types intentionnel et non intentionnel d'inobservance. Ces résultats permettront aux cliniciens de mieux comprendre les facteurs sous-tendant l'hypertension réfractaire. Ils serviront également de base solide pour orienter les recherches futures sur des interventions visant à aborder l'inobservance au traitement médicamenteux et ses sous-types intentionnel et non intentionnel.

The Intentional Non-Adherence Scale (INAS): Initial development and validation.

OBJECTIVE: Adherence continues to be a major challenge in healthcare but there is still limited understanding of all the factors which can influence adherence behaviour. The present study was designed to identify a range of factors associated with intentional non-adherence and to see if they could be formed into a psychometrically sound scale. METHODS: Patients in three different clinical groups (Hypertension (N = 175); Oncology (N = 115); Gout (N = 196)) were given the new scale together with an adherence self-report and/or biomarker measure. Other, more established measures of factors known to be associated with adherence (BMQ, PAM, BIPQ), were also completed by patients for comparative and validation purposes. Exploratory Factor Analysis (EFA) was conducted to examine the factor structure of the new scale, and other statistical analyses were used for testing the psychometric properties of the new scale. RESULTS: EFA revealed two factors, which were labelled "Resisting illness" and "Testing treatment". Both scales were found to have good psychometric properties and explained unique variance in adherence in all three clinical groups. CONCLUSION: This new scale shows promise in describing and explaining some relatively novel factors underlying treatment non-adherence. Further work in different patient groups and clinical contexts is needed to confirm the factor structure and predictive value of these scales.

Factors associated with intentional and unintentional non-adherence to adjuvant endocrine therapy following breast cancer.

Adherence to adjuvant endocrine therapy (AET) following breast cancer is known to be suboptimal despite its known efficacy in reducing recurrence and mortality. This study aims to investigate factors associated with non-adherence and inform the development of interventions to support women and promote adherence. A questionnaire survey to measure level of adherence, side effects experienced, beliefs about medicine, support received and socio-demographic details was sent to 292 women 2-4 years post breast cancer diagnosis. Differences between non-adherers and adherers to AET were explored, and factors associated with intentional and unintentional non-adherence are reported. Approximately one quarter of respondents, 46 (22%), were non-adherers, comprising 29 (14%) intentional non-adherers and 17 (8%) unintentional non-adherers. Factors significantly associated with intentional non-adherence were the presence of side effects (p < .03), greater concerns about AET (p < .001) and a lower perceived necessity to take AET (p < .001). Half of the sample (105/211) reported that side effects had a moderate or high impact on their quality of life. Factors associated with unintentional non-adherence were younger age (<65) (p < .001), post-secondary education (p = .046) and paid employment (p = .031). There are distinct differences between intentional non-adherence and unintentional non-adherence. Differentiation between the two types of non-adherence may help tailor support and advice interventions.