The expert consensus guideline series: Adherence problems in patients with serious and persistent mental illness

Alan S. Bellack, Charles L. Bowden, Christopher R. Bowie, Matthew J. Byerly, William T. Carpenter, Laurel A. Copeland, Albana M Dassori, John M. Davis, Colin A. Depp, Esperanza Diaz, Lisa B. Dixon, John P. Docherty, Eric B. Elbogen, S. Nasser Ghaemi, Paul E. Keck, Samuel J. Keith, Martijn J. Kikkert, John Lauriello, Barry D. Lebotz, Stephen R. MarderJoseph P. McEvoy, David J. Miklowitz, Alexander L Miller, Paul A. Nakonezny, Henry A. Nasrallah, Michael Otto, Roy H. Perlis, Delbert G. Robinson, Gary S. Sachs, Martha Sajatovic, Nina R. Schooler, S. Charles Schulz, Jan Scoff, Jair C. Soares, Stephen M. Strakowski, Holly A. Swartz, Marcia Valenstein, Dawn I Velligan, Peter J. Weiden, Emily M. Woltmann, John E. Zeber

Research output: Contribution to journalArticle

413 Citations (Scopus)

Abstract

Objectives. Poor adherence to medication treatment can have devastating consequences for patients with mental illness. The goal of this project was to develop recommendations for addressing adherence problems to improve patient outcomes. Methods. The editors identified important topics and questions concerning medication adherence problems in serious mental illness that are not fully addressed in the literature. A survey was developed containing 39 questions (521 options) asking about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41(85%) of the 48 experts to whom it was sent. Results of the literature review and survey were used to develop recommendations for assessing and improving adherence in patients with serious mental illness. Results. ASSESSING ADHERENCE: The experts endorsed percentage of medication not taken as the preferred method of defining adherence, with 80% or more of medication taken endorsed as an appropriate cut-off for adherence in bipolar disorder and schizophrenia. Although self- and physician report are the most common methods used to assess adherence in clinical settings, they are often inaccurate and may underestimate nonadherence. The experts recommend that, if possible, clinicians also use more objective measures (e.g., pill counts, pharmacy records, and, when appropriate, serum levels such as are used for lithium). Use of a validated self-report scale may help improve accuracy. SCOPE OF THE PROBLEM: The majority of the experts believed the average patient with schizophrenia or bipolar disorder in their practices takes only 51%-70% of prescribed medication. FACTORS ASSOCIATED WITH NONADHERENCE: The experts endorsed poor insight and lack of illness awareness, distress associated with specific side effects or a general fear of side effects, inadequate efficacy with persistent symptoms, and believing medications are no longer needed as the most important factors leading to adherence problems in schizophrenia and bipolar disorder. The experts considered weight gain a side effect that is very likely to lead to adherence problems in patients with schizophrenia and bipolar disorder; sedation was considered a more important contributor to adherence problems in bipolar disorder than schizophrenia. The experts rated persistent positive or negative symptoms in schizophrenia and persistent grandiosity and manic symptoms in bipolar disorder as the most important symptomatic contributors to adherence problems in these illnesses. INTERVENTIONS: It is important to identify the specific factors that may be contributing to a patient's adherence problems in order to customize interventions to target those problems. Multiple problems may be involved, requiring a combination of interventions. Conclusions. Adherence problems are complex and multi-determined. The experts recommended customized interventions focused on the underlying causes.

Original languageEnglish (US)
Pages (from-to)1-48
Number of pages48
JournalJournal of Clinical Psychiatry
Volume70
Issue numberSUPPL. 4
StatePublished - 2009

Fingerprint

Guideline Adherence
Bipolar Disorder
Schizophrenia
Consensus
Medication Adherence
Patient Compliance
Self Report
Mentally Ill Persons
Lithium
Weight Gain
Fear
Physicians
Serum

ASJC Scopus subject areas

  • Psychiatry and Mental health

Cite this

Bellack, A. S., Bowden, C. L., Bowie, C. R., Byerly, M. J., Carpenter, W. T., Copeland, L. A., ... Zeber, J. E. (2009). The expert consensus guideline series: Adherence problems in patients with serious and persistent mental illness. Journal of Clinical Psychiatry, 70(SUPPL. 4), 1-48.

The expert consensus guideline series : Adherence problems in patients with serious and persistent mental illness. / Bellack, Alan S.; Bowden, Charles L.; Bowie, Christopher R.; Byerly, Matthew J.; Carpenter, William T.; Copeland, Laurel A.; Dassori, Albana M; Davis, John M.; Depp, Colin A.; Diaz, Esperanza; Dixon, Lisa B.; Docherty, John P.; Elbogen, Eric B.; Ghaemi, S. Nasser; Keck, Paul E.; Keith, Samuel J.; Kikkert, Martijn J.; Lauriello, John; Lebotz, Barry D.; Marder, Stephen R.; McEvoy, Joseph P.; Miklowitz, David J.; Miller, Alexander L; Nakonezny, Paul A.; Nasrallah, Henry A.; Otto, Michael; Perlis, Roy H.; Robinson, Delbert G.; Sachs, Gary S.; Sajatovic, Martha; Schooler, Nina R.; Schulz, S. Charles; Scoff, Jan; Soares, Jair C.; Strakowski, Stephen M.; Swartz, Holly A.; Valenstein, Marcia; Velligan, Dawn I; Weiden, Peter J.; Woltmann, Emily M.; Zeber, John E.

In: Journal of Clinical Psychiatry, Vol. 70, No. SUPPL. 4, 2009, p. 1-48.

Research output: Contribution to journalArticle

Bellack, AS, Bowden, CL, Bowie, CR, Byerly, MJ, Carpenter, WT, Copeland, LA, Dassori, AM, Davis, JM, Depp, CA, Diaz, E, Dixon, LB, Docherty, JP, Elbogen, EB, Ghaemi, SN, Keck, PE, Keith, SJ, Kikkert, MJ, Lauriello, J, Lebotz, BD, Marder, SR, McEvoy, JP, Miklowitz, DJ, Miller, AL, Nakonezny, PA, Nasrallah, HA, Otto, M, Perlis, RH, Robinson, DG, Sachs, GS, Sajatovic, M, Schooler, NR, Schulz, SC, Scoff, J, Soares, JC, Strakowski, SM, Swartz, HA, Valenstein, M, Velligan, DI, Weiden, PJ, Woltmann, EM & Zeber, JE 2009, 'The expert consensus guideline series: Adherence problems in patients with serious and persistent mental illness', Journal of Clinical Psychiatry, vol. 70, no. SUPPL. 4, pp. 1-48.
Bellack AS, Bowden CL, Bowie CR, Byerly MJ, Carpenter WT, Copeland LA et al. The expert consensus guideline series: Adherence problems in patients with serious and persistent mental illness. Journal of Clinical Psychiatry. 2009;70(SUPPL. 4):1-48.
Bellack, Alan S. ; Bowden, Charles L. ; Bowie, Christopher R. ; Byerly, Matthew J. ; Carpenter, William T. ; Copeland, Laurel A. ; Dassori, Albana M ; Davis, John M. ; Depp, Colin A. ; Diaz, Esperanza ; Dixon, Lisa B. ; Docherty, John P. ; Elbogen, Eric B. ; Ghaemi, S. Nasser ; Keck, Paul E. ; Keith, Samuel J. ; Kikkert, Martijn J. ; Lauriello, John ; Lebotz, Barry D. ; Marder, Stephen R. ; McEvoy, Joseph P. ; Miklowitz, David J. ; Miller, Alexander L ; Nakonezny, Paul A. ; Nasrallah, Henry A. ; Otto, Michael ; Perlis, Roy H. ; Robinson, Delbert G. ; Sachs, Gary S. ; Sajatovic, Martha ; Schooler, Nina R. ; Schulz, S. Charles ; Scoff, Jan ; Soares, Jair C. ; Strakowski, Stephen M. ; Swartz, Holly A. ; Valenstein, Marcia ; Velligan, Dawn I ; Weiden, Peter J. ; Woltmann, Emily M. ; Zeber, John E. / The expert consensus guideline series : Adherence problems in patients with serious and persistent mental illness. In: Journal of Clinical Psychiatry. 2009 ; Vol. 70, No. SUPPL. 4. pp. 1-48.
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abstract = "Objectives. Poor adherence to medication treatment can have devastating consequences for patients with mental illness. The goal of this project was to develop recommendations for addressing adherence problems to improve patient outcomes. Methods. The editors identified important topics and questions concerning medication adherence problems in serious mental illness that are not fully addressed in the literature. A survey was developed containing 39 questions (521 options) asking about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41(85{\%}) of the 48 experts to whom it was sent. Results of the literature review and survey were used to develop recommendations for assessing and improving adherence in patients with serious mental illness. Results. ASSESSING ADHERENCE: The experts endorsed percentage of medication not taken as the preferred method of defining adherence, with 80{\%} or more of medication taken endorsed as an appropriate cut-off for adherence in bipolar disorder and schizophrenia. Although self- and physician report are the most common methods used to assess adherence in clinical settings, they are often inaccurate and may underestimate nonadherence. The experts recommend that, if possible, clinicians also use more objective measures (e.g., pill counts, pharmacy records, and, when appropriate, serum levels such as are used for lithium). Use of a validated self-report scale may help improve accuracy. SCOPE OF THE PROBLEM: The majority of the experts believed the average patient with schizophrenia or bipolar disorder in their practices takes only 51{\%}-70{\%} of prescribed medication. FACTORS ASSOCIATED WITH NONADHERENCE: The experts endorsed poor insight and lack of illness awareness, distress associated with specific side effects or a general fear of side effects, inadequate efficacy with persistent symptoms, and believing medications are no longer needed as the most important factors leading to adherence problems in schizophrenia and bipolar disorder. The experts considered weight gain a side effect that is very likely to lead to adherence problems in patients with schizophrenia and bipolar disorder; sedation was considered a more important contributor to adherence problems in bipolar disorder than schizophrenia. The experts rated persistent positive or negative symptoms in schizophrenia and persistent grandiosity and manic symptoms in bipolar disorder as the most important symptomatic contributors to adherence problems in these illnesses. INTERVENTIONS: It is important to identify the specific factors that may be contributing to a patient's adherence problems in order to customize interventions to target those problems. Multiple problems may be involved, requiring a combination of interventions. Conclusions. Adherence problems are complex and multi-determined. The experts recommended customized interventions focused on the underlying causes.",
author = "Bellack, {Alan S.} and Bowden, {Charles L.} and Bowie, {Christopher R.} and Byerly, {Matthew J.} and Carpenter, {William T.} and Copeland, {Laurel A.} and Dassori, {Albana M} and Davis, {John M.} and Depp, {Colin A.} and Esperanza Diaz and Dixon, {Lisa B.} and Docherty, {John P.} and Elbogen, {Eric B.} and Ghaemi, {S. Nasser} and Keck, {Paul E.} and Keith, {Samuel J.} and Kikkert, {Martijn J.} and John Lauriello and Lebotz, {Barry D.} and Marder, {Stephen R.} and McEvoy, {Joseph P.} and Miklowitz, {David J.} and Miller, {Alexander L} and Nakonezny, {Paul A.} and Nasrallah, {Henry A.} and Michael Otto and Perlis, {Roy H.} and Robinson, {Delbert G.} and Sachs, {Gary S.} and Martha Sajatovic and Schooler, {Nina R.} and Schulz, {S. Charles} and Jan Scoff and Soares, {Jair C.} and Strakowski, {Stephen M.} and Swartz, {Holly A.} and Marcia Valenstein and Velligan, {Dawn I} and Weiden, {Peter J.} and Woltmann, {Emily M.} and Zeber, {John E.}",
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TY - JOUR

T1 - The expert consensus guideline series

T2 - Adherence problems in patients with serious and persistent mental illness

AU - Bellack, Alan S.

AU - Bowden, Charles L.

AU - Bowie, Christopher R.

AU - Byerly, Matthew J.

AU - Carpenter, William T.

AU - Copeland, Laurel A.

AU - Dassori, Albana M

AU - Davis, John M.

AU - Depp, Colin A.

AU - Diaz, Esperanza

AU - Dixon, Lisa B.

AU - Docherty, John P.

AU - Elbogen, Eric B.

AU - Ghaemi, S. Nasser

AU - Keck, Paul E.

AU - Keith, Samuel J.

AU - Kikkert, Martijn J.

AU - Lauriello, John

AU - Lebotz, Barry D.

AU - Marder, Stephen R.

AU - McEvoy, Joseph P.

AU - Miklowitz, David J.

AU - Miller, Alexander L

AU - Nakonezny, Paul A.

AU - Nasrallah, Henry A.

AU - Otto, Michael

AU - Perlis, Roy H.

AU - Robinson, Delbert G.

AU - Sachs, Gary S.

AU - Sajatovic, Martha

AU - Schooler, Nina R.

AU - Schulz, S. Charles

AU - Scoff, Jan

AU - Soares, Jair C.

AU - Strakowski, Stephen M.

AU - Swartz, Holly A.

AU - Valenstein, Marcia

AU - Velligan, Dawn I

AU - Weiden, Peter J.

AU - Woltmann, Emily M.

AU - Zeber, John E.

PY - 2009

Y1 - 2009

N2 - Objectives. Poor adherence to medication treatment can have devastating consequences for patients with mental illness. The goal of this project was to develop recommendations for addressing adherence problems to improve patient outcomes. Methods. The editors identified important topics and questions concerning medication adherence problems in serious mental illness that are not fully addressed in the literature. A survey was developed containing 39 questions (521 options) asking about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41(85%) of the 48 experts to whom it was sent. Results of the literature review and survey were used to develop recommendations for assessing and improving adherence in patients with serious mental illness. Results. ASSESSING ADHERENCE: The experts endorsed percentage of medication not taken as the preferred method of defining adherence, with 80% or more of medication taken endorsed as an appropriate cut-off for adherence in bipolar disorder and schizophrenia. Although self- and physician report are the most common methods used to assess adherence in clinical settings, they are often inaccurate and may underestimate nonadherence. The experts recommend that, if possible, clinicians also use more objective measures (e.g., pill counts, pharmacy records, and, when appropriate, serum levels such as are used for lithium). Use of a validated self-report scale may help improve accuracy. SCOPE OF THE PROBLEM: The majority of the experts believed the average patient with schizophrenia or bipolar disorder in their practices takes only 51%-70% of prescribed medication. FACTORS ASSOCIATED WITH NONADHERENCE: The experts endorsed poor insight and lack of illness awareness, distress associated with specific side effects or a general fear of side effects, inadequate efficacy with persistent symptoms, and believing medications are no longer needed as the most important factors leading to adherence problems in schizophrenia and bipolar disorder. The experts considered weight gain a side effect that is very likely to lead to adherence problems in patients with schizophrenia and bipolar disorder; sedation was considered a more important contributor to adherence problems in bipolar disorder than schizophrenia. The experts rated persistent positive or negative symptoms in schizophrenia and persistent grandiosity and manic symptoms in bipolar disorder as the most important symptomatic contributors to adherence problems in these illnesses. INTERVENTIONS: It is important to identify the specific factors that may be contributing to a patient's adherence problems in order to customize interventions to target those problems. Multiple problems may be involved, requiring a combination of interventions. Conclusions. Adherence problems are complex and multi-determined. The experts recommended customized interventions focused on the underlying causes.

AB - Objectives. Poor adherence to medication treatment can have devastating consequences for patients with mental illness. The goal of this project was to develop recommendations for addressing adherence problems to improve patient outcomes. Methods. The editors identified important topics and questions concerning medication adherence problems in serious mental illness that are not fully addressed in the literature. A survey was developed containing 39 questions (521 options) asking about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41(85%) of the 48 experts to whom it was sent. Results of the literature review and survey were used to develop recommendations for assessing and improving adherence in patients with serious mental illness. Results. ASSESSING ADHERENCE: The experts endorsed percentage of medication not taken as the preferred method of defining adherence, with 80% or more of medication taken endorsed as an appropriate cut-off for adherence in bipolar disorder and schizophrenia. Although self- and physician report are the most common methods used to assess adherence in clinical settings, they are often inaccurate and may underestimate nonadherence. The experts recommend that, if possible, clinicians also use more objective measures (e.g., pill counts, pharmacy records, and, when appropriate, serum levels such as are used for lithium). Use of a validated self-report scale may help improve accuracy. SCOPE OF THE PROBLEM: The majority of the experts believed the average patient with schizophrenia or bipolar disorder in their practices takes only 51%-70% of prescribed medication. FACTORS ASSOCIATED WITH NONADHERENCE: The experts endorsed poor insight and lack of illness awareness, distress associated with specific side effects or a general fear of side effects, inadequate efficacy with persistent symptoms, and believing medications are no longer needed as the most important factors leading to adherence problems in schizophrenia and bipolar disorder. The experts considered weight gain a side effect that is very likely to lead to adherence problems in patients with schizophrenia and bipolar disorder; sedation was considered a more important contributor to adherence problems in bipolar disorder than schizophrenia. The experts rated persistent positive or negative symptoms in schizophrenia and persistent grandiosity and manic symptoms in bipolar disorder as the most important symptomatic contributors to adherence problems in these illnesses. INTERVENTIONS: It is important to identify the specific factors that may be contributing to a patient's adherence problems in order to customize interventions to target those problems. Multiple problems may be involved, requiring a combination of interventions. Conclusions. Adherence problems are complex and multi-determined. The experts recommended customized interventions focused on the underlying causes.

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