Tailored approach to non-adherence advised in psychotic patients
MedWire News: Treatment adherence therapy (TAT) for patients with psychotic disorders should take into account the reasons for each individual's non-adherence, say researchers who have shown such a strategy to be beneficial.
Study author Anton Staring (Erasmus MC University Medical Center, Tilburg, The Netherlands) and colleagues say the findings are particularly important given that individuals who stop using antipsychotic medication have a three- to five-fold increased risk for relapse and a nearly four-fold increased risk for suicide compared with their adherent peers.
Previous studies of TAT, which incorporates aspects of cognitive-behavioral therapy, have shown mixed findings as to its benefit.
Noting this discordance, recent UK guidelines from the National Institute for Health and Clinical Excellence (NICE) recommend that adherence interventions should not be used in people with schizophrenia.
However, Staring et al speculate that "adherence interventions may be more effective when they take the large variations in reasons for non-adherence into account."
In the current study, the researchers performed a randomized controlled trial of TAT versus treatment as usual (TAU) in 109 outpatients with a DSM-IV diagnosis of schizophrenia or schizoaffective disorder.
The researchers first analyzed determinants of non-adherence, dividing them into three "clusters": (1) denial or concealment of illness and failure to integrate treatment into daily life; (2) dissatisfaction with medication because of its side effects or low efficacy; and (3) deficiency in cognitive skills or lack of daily structure to participate effectively in the treatment.
Reviewing these determinants of non-adherence in patients, the therapists then chose from three treatment modules available: motivational interviewing, medication optimization, and behavioral training.
Staring and team report that patients in the TAT group showed a significantly increased service engagement and medication adherence compared with patients in the TAU group at the end of the 6-month treatment period, with Cohen's d effect sizes of 0.48 and 0.41, respectively - which represent "clinical significance," the researchers say.
Six months after completion of the intervention TAT patients still showed significantly greater service engagement and medication adherence compared with TAU patients, although the effect sizes had reduced somewhat, at 0.39 and 0.30, respectively.
Notably, in the total study period one (1.9%) patient in the TAT group was admitted involuntarily to hospital compared with nine (11.8%) in the TAU group - a borderline significant finding.
"The primary focus of TAT is not on psychoeducation: instead, because it stimulates the person to develop an individual narrative into which treatment can somehow be integrated, individual motives for engagement or adherence may sometimes turn out to be different from what clinicians would find appropriate," Staring et al comment in the British Journal of Psychiatry.
MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010
By Andrew Czyzewski