1、1Adherence to medication in bipolar disorder: a qualitative study exploring the role of patients beliefs about the condition and its treatmentJane Clatworthy1, Richard Bowskill2, Tim Rank3, Rhian Parham1 and Robert Horne11 Centre for Behavioural Medicine, The School of Pharmacy, University of London
2、2 Postgraduate Medical School, University of Brighton3 South Downs Health NHS TrustCorresponding author:Professor Rob HorneDirectorCentre for Behavioural MedicineDepartment of Policy Illness perceptions, Treatment perceptions3Introduction Around 40% of patients diagnosed with bipolar disorder do not
3、 adhere to prescribed medication (1). As nonadherence is associated with higher rates of relapse (2) hospital admission (3) and suicide (4), there is clearly a need for a better understanding of the reasons behind nonadherence in bipolar disorder and for effective interventions to facilitate adheren
4、ce.Whilst much of the existing research exploring nonadherence in bipolar disorder has focussed on demographic and clinical predictors of nonadherence, a recent review of adherence in bipolar disorder highlighted the need for more research that considers active processes in adherence to medication (
5、5). For example, how people make decisions about whether or not to take medication and how people evaluate and manage the consequences of taking medication.One theoretical approach to addressing nonadherence that emphasises the active role of the patient is the perceptions-practicalities framework (
6、6). This approach conceptualises nonadherence as a variable behaviour with both intentional and unintentional causes. Unintentional nonadherence occurs when the patients intentions to take the treatment are thwarted by lack of resources or capacity (e.g. forgetting or misunderstanding instructions).
7、 Intentional nonadherence is the result of a deliberate decision on the part of the patient and is best understood in terms of the beliefs and expectations influencing patients motivation to begin and persist with treatment.It follows that interventions to facilitate adherence are likely to be more
8、effective if they are individualised to the needs of the patient and address both the perceptual and 4practical barriers to adherence. Effective interventions to facilitate adherence to medication in chronic illness are currently elusive (7). This may be because few interventions have been developed
9、 around a suitable theoretical framework, as recommended in MRC guidelines (8). The perceptions-practicalities approach utilises Leventhals self-regulatory model (9) and the necessity-concerns framework (10) to conceptualise the key beliefs influencing adherence. Self Regulatory Model (SRM)The SRM e
10、xplains the cognitive processes underpinning peoples response to health threats. Health threats may be internal (e.g. the experience of symptoms) or external (e.g. a medical diagnosis). People respond by building a mental map or illness representation to enable them to make sense of the threat and d
11、etermine what to do about it. Illness representations have five components: identity, timeline, cause, consequences and control/cure. These can be thought of as the answers to five basic questions about the illness or health threat: What is it? How long will it last? What caused it? What effect will
12、 it have? Can it be controlled or cured? The answers people find to these questions form their mental map. Illness representations also have an emotional as well as a cognitive component. Research across a range of chronic illnesses, including bipolar disorder (11), has shown that illness-related be
13、haviour is related to illness representations (12). Necessity-Concerns Framework The utility of self-regulatory theory in explaining variations in adherence to treatment is enhanced by considering beliefs about treatment as well as illness (10). In the 5NecessityConcerns framework the salient treatm
14、ent beliefs are conceptualised as the patients perceptions of the necessity of their treatment to maintain current and future health, compared with their concerns about the actual and potential adverse effects of their treatment. The utility of this framework in explaining adherence to treatment has
15、 been shown in a variety of chronic illness groups (13), including depression (14). Research has shown that patients beliefs about the need for medication are influenced by their illness representations (15) and concerns are often related to negative attitudes to pharmaceuticals as a whole and to be
16、liefs about the long terms effects of medication or that regular use will lead to dependence or addiction (13). However, although research has identified that some concerns are common across treatments and illness groups, others are specific to the condition and treatment. For this reason an importa
17、nt first step in operationalising the framework for a particular condition is to carry out studies to elicit the particular beliefs within that patient/treatment group. There is currently minimal research exploring patients perceptions of bipolar disorder. Pollack and Aponte (16) conducted a qualita
18、tive study, whereby fifteen inpatients with bipolar disorder were interviewed about their perceptions of their condition. Patients reported models of bipolar disorder that were very different from the medical model of the condition. For example, one participant believed that their condition was a sp
19、ecial gift from God, whilst another believed it was caused by masturbation. Results from this small sample of hospitalised patients (most of whom were hospitalised involuntarily), however, would not be generalisable to the majority of bipolar patients living in the community prescribed prophylactic
20、treatment for bipolar disorder. Furthermore, the study did not explore in detail patients perceptions of medication or adherence.6Although the Necessity-Concerns framework has not yet been tested in bipolar disorder, existing research appears to support the value of such an approach. For example, Ke
21、ck et al. (17) reported that patients perceived need for medication was a key predictor of adherence to medication. Concerns about medication have also been associated with nonadherence; for example, concerns about side effects (18; 19).The aim of this study was to use the perceptions-practicalities
22、 approach as a framework to explore in depth the beliefs that people hold about bipolar disorder and its treatment and how such beliefs might be associated with adherence to prophylactic maintenance treatment for bipolar disorder. This information could be used to assess whether validated measures o
23、f illness perceptions (Illness Perceptions Questionnaire-Revised)(20) and treatment perceptions (Beliefs about Medicines Questionnaire) (21) address the key beliefs held by people with bipolar disorder that might be relevant to adherence decisions.7MethodParticipantsSixteen people with a diagnosis o
24、f bipolar disorder were recruited through consultant psychiatrists in a local NHS Trust. All participants were prescribed prophylactic treatment for bipolar disorder and were treated in outpatient clinics. The medications prescribed for bipolar disorder in the sample are displayed in Table 1. Twelve
25、 of the participants were female and four were male. The mean age was 54 years (range 38 to 69) The Young Mania Rating Scale (YMRS) (22) and the Hamilton Rating Scale for Depression (HRSD) (23) were conducted immediately prior to the interview. The aim was to explore adherence to prophylactic treatm
26、ent for bipolar disorder and therefore people experiencing a severe manic or depressive episode would have been excluded from the study. All participants recruited met the study inclusion criteria of less than 19 on YMRS and less than 18 on the HRSD. A process of sampling to thematic saturation was
27、used, whereby new participants were recruited and interviewed until no new themes were identified.Insert Table 1 about hereProcedureParticipants were given the choice of being interviewed at their home (n=12), at their local outpatient unit (n= 2) or at the university (n=2). The interviews were cond
28、ucted by two researchers; a Specialist Registrar in Adult General Psychiatry (who was not involved in the patients care) and a health psychology researcher.8A semi-structured interview was conducted, using questions broadly based on the perceptions-practicalities framework (6). Initial questions wer
29、e general (e.g. What do you think about your medication for bipolar disorder?) and were followed with prompts based on the theory (e.g. How necessary do you feel the medication is for you?, Do you have any concerns about the medication?). In addition to asking about illness and treatment perceptions
30、, participants were asked about their nonadherence to medication, including stopping the medication, changing the dose of medication and forgetting to take medication. Care was taken to question in a non-judgemental manner. Interviews were recorded on a digital audio recorder and were transcribed ve
31、rbatim.AnalysisThe coding scheme was structured around the Self-Regulation Model and the Necessity-Concerns framework, as there is substantial support for these theoretical models in other illness groups. Transcripts were read by two independent researchers who identified statements in which partici
32、pants beliefs about bipolar disorder (i.e. Identity, Cause, Timeline, Consequences, Cure/Control) and beliefs about treatment (Necessity, Concerns) were related to adherence behaviour. Statements were coded according to the type of illness or treatment perception, using NVivo 2.0 software. As Necess
33、ity and Concerns are broad concepts, these were subdivided into more specific types of concerns and beliefs about the necessity of treatment. Examples of unintentional nonadherence (i.e. nonadherence that was accidental and not directly related to participants beliefs) were also identified. 9Through
34、 a process of consensus and conciliation the researchers reached agreement on the coding of all of the statements regarding adherence to medication. The researchers selected example quotes from each theme to report here. 10ResultsOverview of adherence to medicationOf the sixteen participants intervi
35、ewed, three did not report any nonadherence to medication, eight reported nonadherence in the past and five reported current nonadherence. Nonadherence took various forms. Whilst not taking prescribed medication and taking less than instructed were the most common forms of nonadherence, some partici
36、pants reported taking more than instructed at times. For example,P: I can remember the last time that happened, my god, and I hadnt been taking it lithium and I was taking a hell of a lot - you know, mouthfuls - to try and stabilise myself, but of course its too far gone.I: Right, so you stopped tak
37、ing it for a while and then you tried to balance it out. Ok, so how much would you take then to compensate?P: When youre high you dont really count to tell you the truth. Quite a lot.(P1)In addition, some participants reported experimenting with their medications. I have been really bad sometimes wh
38、en they prescribe me drugs - they give me large quantities of potentially fatal tablets that you can easily take an overdose accidentally or fiddle about. Because you feel so bad all the time, either up or down, you try and find combinations of drugs that make you feel better, and sometimes you migh
39、t hit on something that will work for a little while and then it wont work any moreThe only thing that I came up with is that if I take 200 mg of amisulpride and about 37 mg of dothiepine within 2 hours it would actually take away the paranoia and the manic activity - the hyper mania - completely. It takes 2 hours to work and then lasts about 24 hours, but it wont
