Tim
2006-08-09 12:22:33 UTC
Can psycho-education help improve treatment compliance in bipolar disorders?
<< Back
MedWire ISBD 2006 (Edinburgh, Scotland), August 2, 2006: Combining
pharmacological treatment and psycho-education strategies can have a
positive effect on patient outcomes in bipolar disorders by improving
patient compliance.
Professor Eduard Vieta, Director of the Bipolar Disorders Program at the
University of Barcelonas Hospital Clinic in Barcelona, Spain, reviewed
the issues around patient compliance or adherence during the first
session of the meeting.
Many patients are non-compliant
Despite effective treatments for bipolar disorders being available, a
substantial number of patients may not adhere to taking their medication
exactly as prescribed in the long term.
Professor Vieta cited data highlighting how 40% of patients may not take
their medication properly while 27% of these patients may partially
adhere to their doctors instructions, 13% may not adhere at all [1].
Furthermore, patients who partially adhere may decide to skip doses on
special occasions or at weekends, or take reduced doses of their
medications, he added.
Why dont patients adhere to treatment?
There are many reasons for non-compliance, and these reasons are varied.
Professor Vieta stated that the number one reason for non-adherence is
that patients deny that they have a problem. Indeed, denial of illness
was the reason for over 60% of patients being non-compliant in one study
[2].
The second largest reason was due to side effects of treatment; other
reasons included the patient believing that they were recovering from
their illness and therefore no longer needed treatment, a feeling of a
lack of control over their lives, lapsed prescription, the cost of
medication, and patients missing the feeling of euphoria associated with
manic episodes. Of course, patients may have cited more than one reason
for non-adherence in this study.
Reasons for non-adherence [2]
* Denial of illness
* Treatment side effects
* Belief in recovering from illness
* Lack of control over life
* Lapsed prescription
* Medication cost
* Missed euphoria
Professor Vieta and his colleague Dr. Francesc Colom, also from the
Hospital Clinic in Barcelona, have produced a chart of how the various
reasons for non-compliance interact [4], illustrating the complexity of
the issues involved, from the psychological reasons - such as having
negative feelings about needing medication to control mood or missing
the manic or creative periods - to having personality disorders,
substance abuse, age, physician negativity, and the type of treatment
and side effects. Illness denial is central to all of these issues.
Working on illness denial is the best way to address poor adherence,
Professor Vieta emphasized.
Problems in gauging compliance
Professor Vieta noted that there are problems in determining whether or
not patients are taking their medication properly [3]. Patient
self-assessments are frequently unreliable, as are pill counts, and
patients have even been know to cheat on blood tests, he said. Relatives
or those caring for the patient need to be better informed, as often
they may not be aware that the patient is not complying fully.
The best approach to gauging if a patient is taking his or her
medication as instructed is to use a combination of patient and
caregiver reports, and blood monitoring.
Understanding the patients point of view
The first step to help our patients, besides medication, is to
understand their feelings about the condition, and understand that
nobody would like to be diagnosed with a mental disorder, said
Professor Vieta.
To try to illustrate how patients with a mental condition such as a
bipolar disorder might feel, he showed a couple of photographs of a
unique public toilet located on a street in Amsterdam, The Netherlands,
the outside of which was mirrored so that the general public could not
see in, but that the user could see out.
While the person inside the toilet may feel exposed or ashamed, the
outside viewer would be none the wiser as to what was going on inside.
This, suggested Professor Vieta, is what physicians need to appreciate
about bipolar disorders and communicate with their patients; that what
is visible on the outside may not be the same as what they are feeling
on the inside.
Medication can be an unwanted reminder that the patient is not well, he
added.
Psychotherapy in bipolar disorder
Professor Vieta outlined the main points concerning psychotherapy in
bipolar disorders, noting that the central premise was to help patients
to understand and accept their condition [5].
Psychotherapy is a great help for any situation of human suffering, he
said, when you are suffering from a bipolar disorder, I think the best
help you can get from a professional is to deal with the disease.
Thus psychotherapy should be focussed on the illness and its consequences.
Professor Vieta noted that there is no proof that psychotherapy alone
helps patients, and stressed that acute manic episodes require active
medication.
The data concerning the use of psychotherapy so far, he added, suggest
that psychotherapy works best after medication, that is once remission
of a manic episode is achieved.
Professor Vieta noted that the evidence for the use of psychotherapy in
bipolar disorders was very recent, and included the use of individual
cognitive behavioral therapy, family intervention, and group
intervention. He focussed the remainder of his talk on group
psycho-education.
Psychotherapy: Key points
* Focus on the illness and its consequences
* Works best as adjunctive treatment
* Especially useful in prophylaxis (euthymic patients)
* Not beneficial for all patients
* May have side effects
What are the main goals of group psycho-education?
As with all psychotherapeutic and medical interventions for bipolar
disorders, the primary goals of group psycho-education are to prevent
patients from relapsing, reduce the likelihood that hospitalization will
be required, prevent suicidal behavior, and improve patients ability to
function normally [5].
Putting theory into practice
Integrating a psycho-education program into clinical practice requires
organizational changes, according to Professor Vieta.
Patients need to be followed up long term, and more than one patient may
be ascribed to one doctor.
Keeping an open-door policy for outpatients is advised, as is
flexibility in appointments.
A team approach is essential, with psychiatrists, nurses, and primary
care physicians working together with the patient. Involving the patient
in treatment decisions can be very rewarding, he said.
The didactic approach to patient care should be replaced with a more
interactive relationship, which respects the patients choices, and will
help gain the patients trust.
Involving the patients family or carers is also important to achieve
the best results. The treatment of this condition is more successful if
the relatives or caregivers are involved.
Psycho-education in practice
Outlining the psycho-education program used in his practice [6],
Professor Vieta said that patients need to be in remission (as assessed
by Young Mania Rating Scale and HAM-D scores). Patients are seen in
groups of eight to 12, with two psychiatrists involved. The program
covers all aspects of bipolar disorders, educating patients on the
nature of their disease, how it is treated, and expected outcomes. The
program lasts for a minimum of 6 months.
Data show that such a program helps patients significantly, with fewer
reported relapses, even at 5 years follow up.
However, psycho-education is not without its side effects, said
Professor Vieta. Patients may become dependent on the program and find
it hard to cope once it stops. Patients may also become obsessed with
their own wellbeing and think that they have relapsed at the slightest
change in mood.
Emphasizing the importance of involving the family or caregiver,
Professor Vieta cited data from Reinares et al [7], which showed that
psycho-education improved the perceived burden of bipolar disorders.
How can clinicians improve patient compliance?
Concluding his presentation, Professor Vieta suggested that clinicians
can help improve patient adherence by being aware that this can be a
problem, looking out for such patients, understanding the reasons behind
the non-compliance, monitoring them, and treating as appropriate [3].
He said that providing adequate information to patients was essential,
as was involving the family or caregivers in any psycho-education
programs initiated.
Side effects of medications should be addressed, with every effort made
to make the medication user friendly, or switch to a different
medication or formulation.
References:
1. Colom F, Vieta E, Martinez-Aran A, et al. Clinical factors associated
with treatment noncompliance in euthymic bipolar patients. J Clin
Psychiatry 2000;61:54955.
2. Keck PE Jr, McElroy SL, Strakowski SM, Bourne ML, West SA. Compliance
with maintenance treatment in bipolar disorder. Psychopharmacol Bull
1997;33:8791.
3. Colom F, Vieta E. Non-adherence in psychiatric disorders:
misbehaviour or clinical feature? Acta Psychiatr Scand 2002;105:16472.
4. Colom F, et al. Non-compliance in bipolar disorders: more than a
wrong decision. In: Vieta E, ed. Bipolar disorders: Clinical and
therapeutic progress, 2001:16983.
5. Colom F, Vieta E, Martinez A, Jorquera A, Gasto C. What is the role
of psychotherapy in the treatment of bipolar disorder? Psychother
Psychosom 1998;67:39.
6. Colom F, Vieta E, Martinez-Aran A, et al. A randomized trial on the
efficacy of group psychoeducation in the prophylaxis of recurrences in
bipolar patients whose disease is in remission. Arch Gen Psychiatry
2003;60:402-7.
7. Reinares M, Vieta E, Colom F, et al. Impact of a psychoeducational
family intervention on caregivers of stabilized bipolar patients.
Psychother Psychosom 2004;73:312-9.
<< Back
MedWire ISBD 2006 (Edinburgh, Scotland), August 2, 2006: Combining
pharmacological treatment and psycho-education strategies can have a
positive effect on patient outcomes in bipolar disorders by improving
patient compliance.
Professor Eduard Vieta, Director of the Bipolar Disorders Program at the
University of Barcelonas Hospital Clinic in Barcelona, Spain, reviewed
the issues around patient compliance or adherence during the first
session of the meeting.
Many patients are non-compliant
Despite effective treatments for bipolar disorders being available, a
substantial number of patients may not adhere to taking their medication
exactly as prescribed in the long term.
Professor Vieta cited data highlighting how 40% of patients may not take
their medication properly while 27% of these patients may partially
adhere to their doctors instructions, 13% may not adhere at all [1].
Furthermore, patients who partially adhere may decide to skip doses on
special occasions or at weekends, or take reduced doses of their
medications, he added.
Why dont patients adhere to treatment?
There are many reasons for non-compliance, and these reasons are varied.
Professor Vieta stated that the number one reason for non-adherence is
that patients deny that they have a problem. Indeed, denial of illness
was the reason for over 60% of patients being non-compliant in one study
[2].
The second largest reason was due to side effects of treatment; other
reasons included the patient believing that they were recovering from
their illness and therefore no longer needed treatment, a feeling of a
lack of control over their lives, lapsed prescription, the cost of
medication, and patients missing the feeling of euphoria associated with
manic episodes. Of course, patients may have cited more than one reason
for non-adherence in this study.
Reasons for non-adherence [2]
* Denial of illness
* Treatment side effects
* Belief in recovering from illness
* Lack of control over life
* Lapsed prescription
* Medication cost
* Missed euphoria
Professor Vieta and his colleague Dr. Francesc Colom, also from the
Hospital Clinic in Barcelona, have produced a chart of how the various
reasons for non-compliance interact [4], illustrating the complexity of
the issues involved, from the psychological reasons - such as having
negative feelings about needing medication to control mood or missing
the manic or creative periods - to having personality disorders,
substance abuse, age, physician negativity, and the type of treatment
and side effects. Illness denial is central to all of these issues.
Working on illness denial is the best way to address poor adherence,
Professor Vieta emphasized.
Problems in gauging compliance
Professor Vieta noted that there are problems in determining whether or
not patients are taking their medication properly [3]. Patient
self-assessments are frequently unreliable, as are pill counts, and
patients have even been know to cheat on blood tests, he said. Relatives
or those caring for the patient need to be better informed, as often
they may not be aware that the patient is not complying fully.
The best approach to gauging if a patient is taking his or her
medication as instructed is to use a combination of patient and
caregiver reports, and blood monitoring.
Understanding the patients point of view
The first step to help our patients, besides medication, is to
understand their feelings about the condition, and understand that
nobody would like to be diagnosed with a mental disorder, said
Professor Vieta.
To try to illustrate how patients with a mental condition such as a
bipolar disorder might feel, he showed a couple of photographs of a
unique public toilet located on a street in Amsterdam, The Netherlands,
the outside of which was mirrored so that the general public could not
see in, but that the user could see out.
While the person inside the toilet may feel exposed or ashamed, the
outside viewer would be none the wiser as to what was going on inside.
This, suggested Professor Vieta, is what physicians need to appreciate
about bipolar disorders and communicate with their patients; that what
is visible on the outside may not be the same as what they are feeling
on the inside.
Medication can be an unwanted reminder that the patient is not well, he
added.
Psychotherapy in bipolar disorder
Professor Vieta outlined the main points concerning psychotherapy in
bipolar disorders, noting that the central premise was to help patients
to understand and accept their condition [5].
Psychotherapy is a great help for any situation of human suffering, he
said, when you are suffering from a bipolar disorder, I think the best
help you can get from a professional is to deal with the disease.
Thus psychotherapy should be focussed on the illness and its consequences.
Professor Vieta noted that there is no proof that psychotherapy alone
helps patients, and stressed that acute manic episodes require active
medication.
The data concerning the use of psychotherapy so far, he added, suggest
that psychotherapy works best after medication, that is once remission
of a manic episode is achieved.
Professor Vieta noted that the evidence for the use of psychotherapy in
bipolar disorders was very recent, and included the use of individual
cognitive behavioral therapy, family intervention, and group
intervention. He focussed the remainder of his talk on group
psycho-education.
Psychotherapy: Key points
* Focus on the illness and its consequences
* Works best as adjunctive treatment
* Especially useful in prophylaxis (euthymic patients)
* Not beneficial for all patients
* May have side effects
What are the main goals of group psycho-education?
As with all psychotherapeutic and medical interventions for bipolar
disorders, the primary goals of group psycho-education are to prevent
patients from relapsing, reduce the likelihood that hospitalization will
be required, prevent suicidal behavior, and improve patients ability to
function normally [5].
Putting theory into practice
Integrating a psycho-education program into clinical practice requires
organizational changes, according to Professor Vieta.
Patients need to be followed up long term, and more than one patient may
be ascribed to one doctor.
Keeping an open-door policy for outpatients is advised, as is
flexibility in appointments.
A team approach is essential, with psychiatrists, nurses, and primary
care physicians working together with the patient. Involving the patient
in treatment decisions can be very rewarding, he said.
The didactic approach to patient care should be replaced with a more
interactive relationship, which respects the patients choices, and will
help gain the patients trust.
Involving the patients family or carers is also important to achieve
the best results. The treatment of this condition is more successful if
the relatives or caregivers are involved.
Psycho-education in practice
Outlining the psycho-education program used in his practice [6],
Professor Vieta said that patients need to be in remission (as assessed
by Young Mania Rating Scale and HAM-D scores). Patients are seen in
groups of eight to 12, with two psychiatrists involved. The program
covers all aspects of bipolar disorders, educating patients on the
nature of their disease, how it is treated, and expected outcomes. The
program lasts for a minimum of 6 months.
Data show that such a program helps patients significantly, with fewer
reported relapses, even at 5 years follow up.
However, psycho-education is not without its side effects, said
Professor Vieta. Patients may become dependent on the program and find
it hard to cope once it stops. Patients may also become obsessed with
their own wellbeing and think that they have relapsed at the slightest
change in mood.
Emphasizing the importance of involving the family or caregiver,
Professor Vieta cited data from Reinares et al [7], which showed that
psycho-education improved the perceived burden of bipolar disorders.
How can clinicians improve patient compliance?
Concluding his presentation, Professor Vieta suggested that clinicians
can help improve patient adherence by being aware that this can be a
problem, looking out for such patients, understanding the reasons behind
the non-compliance, monitoring them, and treating as appropriate [3].
He said that providing adequate information to patients was essential,
as was involving the family or caregivers in any psycho-education
programs initiated.
Side effects of medications should be addressed, with every effort made
to make the medication user friendly, or switch to a different
medication or formulation.
References:
1. Colom F, Vieta E, Martinez-Aran A, et al. Clinical factors associated
with treatment noncompliance in euthymic bipolar patients. J Clin
Psychiatry 2000;61:54955.
2. Keck PE Jr, McElroy SL, Strakowski SM, Bourne ML, West SA. Compliance
with maintenance treatment in bipolar disorder. Psychopharmacol Bull
1997;33:8791.
3. Colom F, Vieta E. Non-adherence in psychiatric disorders:
misbehaviour or clinical feature? Acta Psychiatr Scand 2002;105:16472.
4. Colom F, et al. Non-compliance in bipolar disorders: more than a
wrong decision. In: Vieta E, ed. Bipolar disorders: Clinical and
therapeutic progress, 2001:16983.
5. Colom F, Vieta E, Martinez A, Jorquera A, Gasto C. What is the role
of psychotherapy in the treatment of bipolar disorder? Psychother
Psychosom 1998;67:39.
6. Colom F, Vieta E, Martinez-Aran A, et al. A randomized trial on the
efficacy of group psychoeducation in the prophylaxis of recurrences in
bipolar patients whose disease is in remission. Arch Gen Psychiatry
2003;60:402-7.
7. Reinares M, Vieta E, Colom F, et al. Impact of a psychoeducational
family intervention on caregivers of stabilized bipolar patients.
Psychother Psychosom 2004;73:312-9.
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