Teresa Diez

Medication adherence in schizophrenia: factors influencing adherence and consequences of nonadherence, a systematic literature review:

Background: Nonadherence to medication is a recognized problem and may be the most challenging aspect of treatment. Methods: We performed a systematic review of factors that influence adherence and the consequences of nonadherence to the patient, healthcare system and society, in patients with schizophrenia. Particular attention was given to the effect of nonadherence on hospitalization rates, as a key driver of increased costs of care. A qualitative systematic literature review was conducted using a broad search strategy using disease and adherence terms. Due to the large number of abstracts identified, article selection was based on studies with larger sample sizes published after 2001. Thirty-seven full papers were included: 15 studies on drivers and 22 on consequences, of which 12 assessed the link between nonadherence and hospitalization. Results: Key drivers of nonadherence included lack of insight, medication beliefs and substance abuse. Key consequences of nonadherence included greater risk of relapse, hospitalization and suicide. Factors positively related to adherence were a good therapeutic relationship with physician and perception of benefits of medication. The most frequently reported driver and consequence were lack of insight and greater risk of hospitalization respectively. Conclusions: Improving adherence in schizophrenia may have a considerable positive impact on patients and society. This can be achieved by focusing on the identified multitude of factors driving nonadherence.

Prevalence of depression and its relationship with other clinical characteristics in a sample of patients with stable schizophrenia.

AIM To evaluate the prevalence of depression using the Calgary Depression Scale for Schizophrenia (CDSS) in a sample of Spanish patients with stable schizophrenia and without a diagnosis of depression. METHODS We included stable outpatients of 18 to 50 years of age, with a diagnosis of schizophrenia, schizoaffective disorder, or schizophreniform disorder who had not been diagnosed with depression. In this cross-sectional study, we administered the CDSS, the Positive and Negative Syndrome Scale (PANSS), the Scale for the Assessment of Negative Symptoms (SANS), the Scale to Assess Unawareness of Mental Disorder (SUMD), the Simpson Angus Scale (SAS), and the Barnes Akathisia Rating Scale (BARS). RESULTS A total of 95 patients were recruited, 90 of them were included in the statistical analysis. Twenty-eight patients had a total score of 5 or more points on the CDSS, making the prevalence of depression 31% (95% confidence interval, 22-41). The CDSS had a high correlation with the depressive factor of the PANSS and a moderate correlation with the general psychopathology subscale of the PANSS. The correlation of the CDSS total score with negative symptoms was moderate using the SANS and low with the PANSS-negative. There was no correlation between depressive symptoms and positive symptoms, insight, and extrapyramidal symptoms; and the correlation with akathisia was low. CONCLUSION Our results suggest that patients with stable schizophrenia who have not been diagnosed with depression frequently have clinically relevant symptoms of depression, and that these symptoms, with the possible exception of a contribution from negative symptoms, are not secondary to other symptoms of their disorder or to extrapyramidal adverse effects of medications.

Dosing frequency and adherence in chronic psychiatric disease: systematic review and meta-analysis

Background The purpose of this study was to investigate the impact of dosing frequency on adherence in severe chronic psychiatric and neurological diseases. Methods: A systematic literature review was conducted for articles in English from medical databases. Diseases were schizophrenia, psychosis, epilepsy, bipolar disorder, and major depressive disorder. Results: Of 1420 abstracts screened, 12 studies were included. Adherence measures included Medication Event Monitoring System (MEMS®), medication possession ratio, medication persistence, and refill adherence. Three schizophrenia and one epilepsy study used MEMS, and all showed a trend towards higher adherence rates with less frequent dosing regimens. Three depression and one schizophrenia study used the medication possession ratio; the pooled odds ratio of being adherent was 89% higher (ie, 1.89, 95% credibility limits 1.71–2.09) on once-daily versus twice-daily dosing. Two studies in depression and one in all bupropion patients assessed medication persistence and refill adherence. The pooled odds ratio for the two depression studies using medication persistence was 2.10 (95% credibility limits 1.86–2.37) for once-daily versus twice-daily dosing. For refill adherence after 9 months, 65%–75% of patients on once-daily versus 56% on twice-daily dosing had at least one refill. In all but one of the studies using other measures of adherence, adherence rates were higher with once-daily dosing compared with more frequent dosing regimens. No relevant studies were identified for bipolar disorder or psychosis. Conclusion: Differences in study design and adherence measures used across the studies were too large to allow pooling of all results. Despite these differences, there was a consistent trend of better adherence with less frequent dosing.

Pattern of healthcare resource utilization and direct costs associated with manic episodes in Spain

BackgroundAlthough some studies indicate that bipolar disorder causes high health care resources consumption, no study is available addressing a cost estimation of bipolar disorder in Spain. The aim of this observational study was to evaluate healthcare resource utilization and the associated direct cost in patients with manic episodes in the Spanish setting.MethodsRetrospective descriptive study was carried out in a consecutive sample of patients with a DSM-IV diagnosis of bipolar type I disorder with or without psychotic symptoms, aged 18 years or older, and who were having an active manic episode at the time of inclusion. Information regarding the current manic episode was collected retrospectively from the medical record and patient interview.ResultsSeven hundred and eighty-four evaluable patients, recruited by 182 psychiatrists, were included in the study. The direct cost associated with healthcare resource utilization during the manic episode was high, with a mean cost of nearly €4,500 per patient, of which approximately 55% corresponded to the cost of hospitalization, 30% to the cost of psychopharmacological treatment and 10% to the cost of specialized care.ConclusionsOur results show the high cost of management of the patient with a manic episode, which is mainly due to hospitalizations. In this regard, any intervention on the management of the manic patient that could reduce the need for hospitalization would have a significant impact on the costs of the disease.

Impact of depressive symptoms on subjective well-being: the importance of patient-reported outcomes in schizophrenia

Objective The subjective experience of psychotic patients toward treatment is a key factor in medication adherence, quality of life, and clinical outcome. The aim of this study was to assess the subjective well-being in patients with schizophrenia and to examine its relationship with the presence and severity of depressive symptoms. Methods A multicenter, cross-sectional study was conducted with clinically stable outpatients diagnosed with schizophrenia. The Subjective Well-Being under Neuroleptic Scale – short version (SWN-K) and the Calgary Depression Scale for Schizophrenia (CDSS) were used to gather information on well-being and the presence and severity of depressive symptoms, respectively. Spearman’s rank correlation was used to assess the associations between the SWN-K total score, its five subscales, and the CDSS total score. Discriminative validity was evaluated against that criterion by analysing the area under the curve (AUC). Results Ninety-seven patients were included in the study. Mean age was 35 years (standard deviation = 10) and 72% were male. Both the total SWN-K scale and its five subscales correlated inversely and significantly with the CDSS total score (P < 0.0001). The highest correlation was observed for the total SWN-K (Spearman’s rank order correlation [rho] = −0.59), being the other correlations: mental functioning (−0.47), social integration (−0.46), emotional regulation (−0.51), physical functioning (−0.48), and self-control (−0.41). A total of 33 patients (34%) were classified as depressed. Total SWN-K showed the highest AUC when discriminating between depressive severity levels (0.84), followed by emotional regulation (0.80), social integration (0.78), physical functioning and self-control (0.77), and mental functioning (0.73). Total SWN-K and its five subscales showed a significant linear trend against CDSS severity levels (P < 0.001). Conclusion The presence of moderate to severe depressive symptoms was relatively high, and correlated inversely with patients’ subjective well-being. Routine assessment of patient-reported measures in patients with schizophrenia might reduce potential discrepancy between patient and physician assessment, increase therapeutic alliance, and improve outcome.

Telephone-based nursing strategy to improve adherence to antipsychotic treatment in schizophrenia: A controlled trial

Abstract Objective. Adherence to prescribed antipsychotic medication is a major factor in achieving optimal long-term clinical outcomes. The aim of this study was to evaluate the impact of a telephone-based strategy provided by a nurse on adherence to antipsychotic treatment among patients with schizophrenia. Methods. A total of 928 clinically stable outpatients with schizophrenia were randomized to receive a monthly telephone call by a nurse or routine clinical care. Telephone calls were performed at weeks 4, 8, and 12, consisting of a standardized interview to detect and assess therapeutic adherence and subjective attitude towards medication. Patients were followed for 4 months. A cut-point of ≥ 60% of prescribed dose was used to classify patients as being adherent. Results. At week 16, a significantly higher percentage of patients who received a telephone-based follow-up (96.7%, n = 410) were classified as adherent compared to the control group (91.2%, n = 402) (P = 0.0007). Patients in the intervention group were significantly more likely to be adherent than control group (adjusted OR = 3.3 95% CI 1.6–6.6, P = 0.0001). Conclusions. Telephone-based nursing strategy showed a significant improvement in adherence to antipsychotic drugs. Further studies are necessary to confirm if this kind of intervention could be a complementary strategy to optimize adherence in patients with schizophrenia.

Estimation of a multiattribute utility function for the Spanish version of the TooL questionnaire.

OBJECTIVES To estimate and assess the psychometric properties of a multiattribute utility function (MAUF) for the Spanish version of the Tolerability and Quality of Life (TooL questionnaire). METHODS Balanced data on 243 patients diagnosed with schizophrenia or bipolar disorder were gathered. In addition to the demographic and clinical variables and the usual generic health-related quality of life (HRQoL) questionnaires (EuroQol-5D [EQ-5D] and Short Form-6D [SF-6D]), instruments considered included the Spanish versions of the Positive and Negative Symptoms of Schizophrenia Scale (PANSS), Young Mania Rating Scale (YMRS), Montgomery-Asberg Depression Rating Scale (MADRS), Udvalg for Kliniske Undersogelser (UKU), and Clinical Global Impression Severity (CGIS) scale. MAUF parameters estimation involved a number of visual analogue scale (VAS) and time trade-off (TTO) ratings that proved difficult to be performed by the patients. After checking for inconsistencies in patient responses, the original sample was reduced to a still balanced subsample of 70 individuals. A multiplicative-form MAUF was estimated following the standard methodology. RESULTS Good convergent validity was demonstrated because utility estimates from the MAUF presented strong correlations with utilities from the generic HRQoL instruments included: SF-6D (0.66, P < 0.01), EQ-5D (0.69, P < 0.01), and moderate correlations with the rest of instruments considered: PANSS (-0.27, P = 0.10), YMRS (-0.30, P = 0.08), MADRS (-0.48, P < 0.01), UKU (-0.35, P < 0.01). Criterion validity was also met because differences in mean utilities by clinical severity were found (P < 0.01). Utilities from the MAUF covered a wider range of health states [0.04,1.00] than those from the SF-6D [0.53,1.00] and EQ-5D [0.23,0.96]. CONCLUSIONS Utilities from the MAUF showed good psychometric properties, serving as a complement to generic health utilities. If misapplied, however, utilities from this instrument might favor the positive evaluation of drugs showing fewer associated side effects.

PMH43 THE SPANISH VERSION OF THE TOOL QUESTIONNAIRE: A USEFUL MEASURE FOR EVALUATING THE HRQOL AND UTILITIES FROM SCHIZOPHRENIC AND BIPOLAR PATIENTS

PMH42 HEALTH-RELATED QUALITY OF LIFE OF MARRIED,WORKING WOMENWITH CHILDREN (SUPERWOMAN SYNDROME) IN KOREA Kim S, Park S, Park H Kyung Hee University, Seoul, South Korea, Kyung Hee University, Yongin, Gyeonggi-Do, South Korea, Pochon CHA University, Sungnam, Gyeonggi-Do, South Korea OBJECTIVES: To assess health-related quality of life (QoL) of married, working women with children (working-moms) faced with psychosocial stress (known as superwoman syndrome). METHODS: A total of 200 working-moms (aged 40.2 5.3) were recruited randomly by telephone, and a questionnaire was administered to classify types of superwomen syndrome: selfreliance type (ST), conflict type (CT), and additive type (AT). To compare, a community samples of aged group (n = 80, aged 70.0 5.9) were recruited at a local community center. We measured QoL using SF-36v2 for both groups. RESULTS: As expected younger working-moms reported significantly higher physical function (PF: 79.7 18.7 vs. 71.9 21.9; p = .0031) and mental health (MH: 49.2 15.3 vs. 41.0 14.8; p < .0001). On the contrary role-physical (RP: 78.9 23.6 vs. 80.5 22.5) and role-emotional (RE: 77.2 25.0 vs. 83.2 24.0) scores were lower than aged. Additionally, social functioning (SF) was significantly lower in working-moms (p < .0003). Further by types, most physical-related scales of ST group (n = 10) were significantly higher (all p’s < 0.0025), whereas vitality (VT) and MH were lower than aged.Majority of working-momswere classified as CT group (n = 169). They reported the same QoL patterns as total samples. Notably, AT group (n = 21) reported only MH (62.9 13.8 vs. 41.0 14.8; p < 0.0001) was significantly higher than aged, and rest were either similar (PF, VT), or significantly lower than aged (RP: 62.8 24.6 vs. 80.5 22.5, RE: 55.1 26.6 vs. 83.2 24.0; all p’s < 0.002). CONCLUSIONS: Most workingmoms reported higher functioning and well-being, but in fact they were limited in playing roles due to physical andmental problems. It is suspected that they are denying and suppressing their various health problems. Particularly, additive group report they are in well-being, but the study showed they are definitely not. They even may develop mentally and physically-related diseases in the near future. Therefore, a cohort study is urgent for working, married women with children in Korea.

P03-123 - Validation of the Spanish version of the subjective well-being under neuroleptic scale (SWN) in patients with schizophrenia

Objective To assess the psychometric properties of the Spanish version of the SWN scale, an instrument which evaluates the subjective experience of psychotic patients towards neuroleptic treatment. Methods A validation study (feasibility, reliability, and validity) was conducted in 20 psychiatric centers. Patients were evaluated with the PANSS, the CGI severity scale and the SWN-20. A re-test was conducted one week after baseline. The study included clinically stabilized outpatients diagnosed with schizophrenia (DSM-IV-TR criteria) who were on treatment as usual. The SWN used in this study consists of 20 questions answered on a 6-point Likert scale. The total score ranges from 20 to 120 points (higher scores indicating better well-being). The original version was back-translated and a focus group was conducted to improve the comprehension of the items. Results 97 patients were included. Seventy-two percent of them (70) were male. Mean age was 35 years (SD = 10.0). Mean SWN total score: 83.5 (SD = 14.0). Internal homogeneity: 0.86. Test-retest in clinically stable patients was 0.89. SWN correlated significantly with the PANSS, but not with the DAI-10. Patients with none-mild clinical affectation had higher SWN scores, indicating a better subjective well-being, and vice versa. Conclusions The subjective experience of psychotic patients towards treatment is a key factor in therapeutic adherence, quality of life, and clinical outcome. The Spanish version of the SWN scale showed good psychometric properties in a sample of schizophrenic stabilized outpatients. SWN scale constitutes a valuable addition to evaluate patients’ subjective well-being.

P03-95 - Factors associated with the effectiveness of a telephone-based nursing strategy for enhancing adherence to antipsychotic treatment in schizophrenia

Objective A randomized, controlled study showed that a telephone-based nursing strategy was effective to improve adherence to antipsychotic treatment in clinically stable outpatients with schizophrenia. Post hoc analysis was carried out to identify factors associated with intervention success. Methods Patients (n= 865) were randomized to receive monthly telephone calls from a nurse or standard clinical follow-up. Calls were performed at weeks 4, 8, and 12, consisting of a brief semistructured interview to assess adherence and attitudes toward medication (DAI-10). Primary endpoint: difference in the percentage of adherent patients after phone follow-up versus control group at week 16. Non conditional logistic regression with backward stepwise procedure was used to identify variables involved with adherence improvement. Results 410 (96.7%) patients fulfilled adherence criteria in the intervention group vs 402 (91.1%) in the control group. A difference of 5.5% was found between groups (95% CI 2.3, 8.6%; p= 0.0007). The telephone intervention was significantly associated with an improvement in adherence in those patients with a prior negative attitude toward treatment (OR 4.7, 95% CI 2.4, 9.0; p Conclusions A nurse telephone follow-up could be a complementary and easy to implement strategy to improve therapeutic adherence, particularly in those patients with negative attitudes toward antipsychotic treatment.