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2000 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2000 Volume 4 Pages 81 ± 82
81
Topics in contemporary psychiatric practice Compliance in major psychoses A CARLO ALTAMURA1 and GIN S MALHI2
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 11/18/14 For personal use only.
1
Department of Psychiatry, University of Milan and 2 Department of Psychiatry, University of New South Wales
Correspondence Address Prof A. Carlo Altamura, Department of Psychiatry, University of Milan, Italy. E-mail: [email protected]
T
housands of articles have been written on the topic of compliance and yet it is seldom discussed . It is therefore poorly understood and indeed the term itself has varied usage. The situation is further complicated by the fact that complianc e is not `all or none’. Clinically , it is essential to consider issues of compliance at every stage of management and to be aware of the characteristic s of patients more likely to be non-complain t. Compliance plays a crucial role in determining the degree of response to psychotropic medication during the different phases of treatment, namely, acute, stabilizatio n and maintenance; and it is often an issue in cases of treatment resistance. In the major psychose s complianc e has been reported to range from 40% to 50% and from 25% to 50% in those treated with neuroleptics and antidepressants, respectively . Even so, the true impact of poor complianc e on the overall management of major psychoses is probably underestimat ed as there are no reliable means for its assessment , particularl y in everyday clinical practice. Many factors influence complianc e and these can be broadly considered as those relating to the patient, the patient’s environmen t and those pertaining to the treatment. The patient’s awareness and acceptance of their illness is a necessary pre-requisite . The deterioration of insight in certain psychiatric conditions, such as schizophrenia and severe mood disorders, is of key importance in preventing satisfactory adherence to therapy and this underpins the need to educate both the patient and their significan t others about the nature of the psychiatri c disorder . In doing so it is important to point out the early clinical signs of the illness and the risks linked to the lack of proper therapy and emphasize the need for treatment. A psycho-educa tional approach should stress the importance
of taking medications as prescribed whilst at the same time providing reassuranc e and information. Aspects relating to drug administratio n that can positively influenc e the patient’s treatment adherence include drug efficacy or `effectivenes s’, and drug posology. Where possible the dose should be titrated in order to minimize both the onset of adverse reactions and the number of daily administration s. Naturally drugs with a short latency of action, a good tolerability profile and few drug ± drug interactions should be given preference . In this context the main therapeutic advantage of newer antidepressa nt and antipsychotic compounds is a more favourable side-effec t profile which can significant ly enhance drug compliance. The use of the novel compounds for the treatment of major psychoses often enables patients to continue functioning, for instance in terms of work or study, and results in better social adjustment. This in turn probably reduces the likelihood of voluntary interruption of therapy. Many other aspects of clinical management play a significan t role. These include the latency between the onset of symptoms and the implementation of effective treatment, the frequency of check-ups, the level to which treatment is tailored to the individua l needs of the patient, the attitude of staff towards the treatment, and the integration between inpatient and outpatient services. Finally, it is important to bear in mind that compliance is also affected by comorbid illnesses as comorbidit y increases the complexity of therapy and often necessitates polypharmac y. The recommended literature focuses on the major psychoses although naturally this is an issue that affects the management of all psychiatric disorders .
RECOMMENDED LITERATURE SCHIZOPHRENIA 1. Altamura AC (1992) A multidimensi onal (pharmacokin etic and clinical-biolo gical) approach to neuroleptic response in schizophreni a with particular reference to drug resistance. Schizophr Res 8: 187 ± 98. This paper deals with the basis of neuroleptic-re sistance phenomena in schizophreni a, including compliance. Rich bibliograph y.
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2. Kane JM, Rifkin A, Woerner M et al (1983) Low dose neuroleptic treatment of outpatient schizophre nics. I. Preliminar y results for relapse rates. Arch Gen Psychiatr y 40: 893 ± 96. A good paper focussing on the risks and benefits of low-dose maintenanc e therapy in psychotic patients. 3. Hogarty GE, Anderson CM, Reiss DJ et al (1986) Family education, social skills, training, and maintenance chemotherapy in the after care for schizophreni a. Arch Gen Psychiatr y 43: 633 ± 42. A comprehensiv e review of the role of the family in the management of the schizophreni c patients.
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 11/18/14 For personal use only.
4. Fleischhake r WW, Meise U, Gunther V et al (1994) Compliance with antipsychotic drug treatment. Influence of sideeffects. Acta Psychiatr Scand 89 (suppl 382): 11 ± 5. This paper emphasize s the importanc e of considerin g tolerabilit y in short, medium and long-term therapeuti c strategie s.
AFFECTIVE DISORDERS 5. Altamura AC, Mauri M (1985) Plasma concentrations, information and therapy adherence during long-term treatment with antidepressa nts. Br J Clin Pharmacol 20: 714 ± 16. This paper shows the importanc e of pharmacolog ical factors and the use of a psycho-educat ional approac h to optimize compliance in depressed patients. 6. Montgomery SA, Kasper S (1995) Compariso n of compliance between serotonin reuptake inhibitors and tricyclic antidepressan ts: a meta-analysis . Int Clin Psychophar macol 9 (suppl 4): 33 ± 40. A good meta-analysi s which demonstrate s the role of drug tolerabilit y for the depressed patient’s adherence to treatment.
GENERAL Altamura AC (1990) Drug-resist ance phenomena in major psychoses : their discriminatio n and causal mechanisms . Clin Neuropsychop harmacol 13 (suppl 1): 1 ± 15. A definitio n of the concept of drug resistanc e and an analysis of its aetiopathog enetic determinant s. 8. Kane JM (1997) What can we achieve by implementing a complianc e improvemen t program? Int Clin Psychophar macol 12 (suppl 1): 43 ± 46. This is a brief but useful paper that discusses the importanc e of complianc e with treatments in psychiatry . 9. Bebbington PE (1995) The content and the context of compliance . Int Clin Psychopharm acol 9 (suppl 5): 41 ± 50. An interesting and complete account of the various aspects that can influence adherence to treatment in mental disorders .
2000 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2000 Volume 4 Pages 81 ± 82
81
Topics in contemporary psychiatric practice Compliance in major psychoses A CARLO ALTAMURA1 and GIN S MALHI2
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 11/18/14 For personal use only.
1
Department of Psychiatry, University of Milan and 2 Department of Psychiatry, University of New South Wales
Correspondence Address Prof A. Carlo Altamura, Department of Psychiatry, University of Milan, Italy. E-mail: [email protected]
T
housands of articles have been written on the topic of compliance and yet it is seldom discussed . It is therefore poorly understood and indeed the term itself has varied usage. The situation is further complicated by the fact that complianc e is not `all or none’. Clinically , it is essential to consider issues of compliance at every stage of management and to be aware of the characteristic s of patients more likely to be non-complain t. Compliance plays a crucial role in determining the degree of response to psychotropic medication during the different phases of treatment, namely, acute, stabilizatio n and maintenance; and it is often an issue in cases of treatment resistance. In the major psychose s complianc e has been reported to range from 40% to 50% and from 25% to 50% in those treated with neuroleptics and antidepressants, respectively . Even so, the true impact of poor complianc e on the overall management of major psychoses is probably underestimat ed as there are no reliable means for its assessment , particularl y in everyday clinical practice. Many factors influence complianc e and these can be broadly considered as those relating to the patient, the patient’s environmen t and those pertaining to the treatment. The patient’s awareness and acceptance of their illness is a necessary pre-requisite . The deterioration of insight in certain psychiatric conditions, such as schizophrenia and severe mood disorders, is of key importance in preventing satisfactory adherence to therapy and this underpins the need to educate both the patient and their significan t others about the nature of the psychiatri c disorder . In doing so it is important to point out the early clinical signs of the illness and the risks linked to the lack of proper therapy and emphasize the need for treatment. A psycho-educa tional approach should stress the importance
of taking medications as prescribed whilst at the same time providing reassuranc e and information. Aspects relating to drug administratio n that can positively influenc e the patient’s treatment adherence include drug efficacy or `effectivenes s’, and drug posology. Where possible the dose should be titrated in order to minimize both the onset of adverse reactions and the number of daily administration s. Naturally drugs with a short latency of action, a good tolerability profile and few drug ± drug interactions should be given preference . In this context the main therapeutic advantage of newer antidepressa nt and antipsychotic compounds is a more favourable side-effec t profile which can significant ly enhance drug compliance. The use of the novel compounds for the treatment of major psychoses often enables patients to continue functioning, for instance in terms of work or study, and results in better social adjustment. This in turn probably reduces the likelihood of voluntary interruption of therapy. Many other aspects of clinical management play a significan t role. These include the latency between the onset of symptoms and the implementation of effective treatment, the frequency of check-ups, the level to which treatment is tailored to the individua l needs of the patient, the attitude of staff towards the treatment, and the integration between inpatient and outpatient services. Finally, it is important to bear in mind that compliance is also affected by comorbid illnesses as comorbidit y increases the complexity of therapy and often necessitates polypharmac y. The recommended literature focuses on the major psychoses although naturally this is an issue that affects the management of all psychiatric disorders .
RECOMMENDED LITERATURE SCHIZOPHRENIA 1. Altamura AC (1992) A multidimensi onal (pharmacokin etic and clinical-biolo gical) approach to neuroleptic response in schizophreni a with particular reference to drug resistance. Schizophr Res 8: 187 ± 98. This paper deals with the basis of neuroleptic-re sistance phenomena in schizophreni a, including compliance. Rich bibliograph y.
82
AC Altamura and GS Malhi
2. Kane JM, Rifkin A, Woerner M et al (1983) Low dose neuroleptic treatment of outpatient schizophre nics. I. Preliminar y results for relapse rates. Arch Gen Psychiatr y 40: 893 ± 96. A good paper focussing on the risks and benefits of low-dose maintenanc e therapy in psychotic patients. 3. Hogarty GE, Anderson CM, Reiss DJ et al (1986) Family education, social skills, training, and maintenance chemotherapy in the after care for schizophreni a. Arch Gen Psychiatr y 43: 633 ± 42. A comprehensiv e review of the role of the family in the management of the schizophreni c patients.
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 11/18/14 For personal use only.
4. Fleischhake r WW, Meise U, Gunther V et al (1994) Compliance with antipsychotic drug treatment. Influence of sideeffects. Acta Psychiatr Scand 89 (suppl 382): 11 ± 5. This paper emphasize s the importanc e of considerin g tolerabilit y in short, medium and long-term therapeuti c strategie s.
AFFECTIVE DISORDERS 5. Altamura AC, Mauri M (1985) Plasma concentrations, information and therapy adherence during long-term treatment with antidepressa nts. Br J Clin Pharmacol 20: 714 ± 16. This paper shows the importanc e of pharmacolog ical factors and the use of a psycho-educat ional approac h to optimize compliance in depressed patients. 6. Montgomery SA, Kasper S (1995) Compariso n of compliance between serotonin reuptake inhibitors and tricyclic antidepressan ts: a meta-analysis . Int Clin Psychophar macol 9 (suppl 4): 33 ± 40. A good meta-analysi s which demonstrate s the role of drug tolerabilit y for the depressed patient’s adherence to treatment.
GENERAL Altamura AC (1990) Drug-resist ance phenomena in major psychoses : their discriminatio n and causal mechanisms . Clin Neuropsychop harmacol 13 (suppl 1): 1 ± 15. A definitio n of the concept of drug resistanc e and an analysis of its aetiopathog enetic determinant s. 8. Kane JM (1997) What can we achieve by implementing a complianc e improvemen t program? Int Clin Psychophar macol 12 (suppl 1): 43 ± 46. This is a brief but useful paper that discusses the importanc e of complianc e with treatments in psychiatry . 9. Bebbington PE (1995) The content and the context of compliance . Int Clin Psychopharm acol 9 (suppl 5): 41 ± 50. An interesting and complete account of the various aspects that can influence adherence to treatment in mental disorders .
