SOCW 6443 WK 11 Discussion 1: Medication Adherence and Interprofessional Collaboration
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SOCW6443Wk11resource2.pdf
Journal of Human Behavior in the Social Environment, 19:512–530, 2009
Copyright © Taylor & Francis Group, LLC
ISSN: 1091-1359 print/1540-3556 online
DOI: 10.1080/10911350902987987
How Effective are Interventions to Enhance Adherence to Psychiatric Medications? Practice Implications for Social Workers Working With Adults Diagnosed With Severe Mental Illness
LISA TOWNSEND School of Social Work and Center for Education and Research on Mental Health
Therapeutics, Rutgers University, New Brunswick, New Jersey
This study integrates eight systematic reviews of adherence en-
hancement interventions to develop practice guidelines for social
workers who work with adults who do not adhere to prescribed
psychiatric medications. Findings indicate that existing investi-
gations are disparate in their adherence definitions, methodolo-
gies employed, and sampling strategies, rendering it difficult to
construct overall guidelines for social work practice. However,
themes associated consistently with increased adherence are col-
laboration between clients and providers regarding medication
decisions, consistent follow-up care, and a comprehensive network
of professionals and caregivers who support clients in their use of
medication to facilitate stabilization of mental health symptoms.
KEYWORDS Mixed methods, mental health, medication, adher-
ence
INTRODUCTION
The effectiveness of psychotropic medications in alleviating symptoms of psychiatric disorders has been documented widely (Kane, 1989; Katon, Korff, & Lin, 1992; Kennedy, Song, Hunter, Clarke, & Gilbody, 2000; Marder, 1999; Quraishi & David, 2000; Thornley, Adams, & Awad, 2000; Wahlbeck, Cheine, & Essali, 2000). However, despite their effectiveness in ameliorating symp- toms, adherence to psychotropic medications among adult patients is con-
Address correspondence to Lisa Townsend, School of Social Work, Rutgers University, 536 George Street, New Brunswick, NJ 08901. E-mail: [email protected]
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Adherence Enhancement 513
sistently low (Dolder, Lacro, Leckband, & Jeste, 2003). Fenton, Blyler, and Heinssen (1997) found adherence rates in adults with schizophrenia ranging from 11% to 80%. Breen and Thornhill (1998) demonstrated adherence rates between 20% and 80% in a similar sample. Babiker (1986) and Weiden and Olfson (1995) conservatively estimate nonadherence rates at 50% in adult patients with schizophrenia in the first year after hospitalization. Maddox, Levi, & Thompson (1994) showed that premature discontinuation of antide- pressant medication was prevalent in their study of depressed adults.
Nonadherence is particularly concerning given its strong association with symptom relapse. According to Fenton et al. (1997), nonadherent pa- tients are 3.7 times more likely to relapse than patients who take psychotropic medications as prescribed. Fortney, Rost, Zhang, & Pyne (2001) found a strong association between nonadherence and treatment failure resulting in chronic symptomatology. Weiden & Olfson (1995) demonstrated a link between reduced medication adherence and rehospitalization in their study of adult patients with schizophrenia. Weiden & Glazer (1997) later demon- strated that increased utilization of expensive inpatient services (‘‘the revolv- ing door phenomenon’’) was related to lack of adherence to psychotropic prescriptions. Most concerning is the relation between discontinuation of particular pharmacologic agents and increased risk of completed suicide in adults (Muller-Oerlinghausen, Muser-Causemann, & Volk, 1992).
Nonadherence to psychiatric medications is a recurrent theme in social work with adults who have severe mental illness. Floersch (2002, pg. 31) and Longhofer, Floersch, and Jenkins (2003) identified the ‘‘social grid of community medication management’’ in adult treatment of mental health disorders. They articulate the complex ‘‘social grid’’ that interacts to form interpretations of the effectiveness of psychotropic medications. The grid is composed of multiple members who perform different functions in helping individuals manage their mental health care, including psychiatrists, case managers, friends, relatives, and caregivers. Social workers form an integral part of this grid, helping clients remember to take medications, delivering medications, assisting with prescription refills, and counseling clients about possible consequences of nonadherence. Currently, there are no practice guidelines to inform social workers how best to help their clients adhere to psychiatric medications.
The focus of this article is to summarize adherence intervention research by organizing the results of existing systematic reviews. This follows rec- ommendations of the Cochrane Group (2005), the Campbell Collaboration (2005), and Cook, Greengold, Ellrodt, & Weingarten (1997), in which system- atic reviews are synthesized into practice guidelines so that their conclusions may be employed effectively by practitioners. Theoretical models of medica- tion adherence are summarized as a framework for interpreting the empirical evidence. Subsequently, the methodological rigor of the intervention studies contained in the reviews is assessed using two criteria: conceptual adequacy
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and quality of research methodology. In addition, Proctor and Rosen’s (2000) rubric for creating practice guidelines is used to evaluate the usefulness of the results for creating practice guidelines. They recommend that practice guidelines in social work address the following areas: specification of out- come targets, presentation of a comprehensive array of intervention options, criteria for practitioner choice of interventions, and delineation of gaps in empirical knowledge and limitations of the research. Evidence is presented that the research methods employed to date have not generated conclusive data to inform practice guidelines and that refinements in research method- ology are needed. Interventions that show promise for increasing adherence are described, and themes consistently represented in successful intervention outcomes are highlighted for incorporation into social work practice.
ADHERENCE MODELS
Several theoretical models provide a conceptual framework for understand- ing adherence enhancement interventions. These models of adherence can provide a foundation for understanding the mechanisms underlying adher- ence.
Sick Role Theory
Perkins (2002) reviewed existing models that have been applied to nonadher- ence. Bebbington (1995) adapted Parsons’s (1951) concept of the ‘‘sick role’’ to explain the role that patient passivity plays in contributing to nonadher- ence. According to sick role concepts, patients are relieved from traditional involvement in everyday social activities, such as childrearing or work, by their status as ‘‘ill.’’ It is theorized that the sick role generates passivity on the part of patients, decreasing their motivation to play an active role in aspects of care such as medication management. Despite the interesting possibilities offered by sick role theory, no known studies employing it have been published to date in the adherence enhancement literature.
Side Effect Models
Side effect models generated a significant body of empirical work after the emergence of traditional neuroleptics and even greater research interest since the introduction of atypical antipsychotic medications. Fenton et al. (1997) and Perkins (2002) review evidence suggesting that high levels of side effects are linked with nonadherence. Bartko et al. (2002) examined differences in the tolerability of typical versus atypical antipsychotic medications in adults with chronic schizophrenia, finding that patients preferred atypical agents over conventional medications. These studies have motivated efforts
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to develop medications with lower side effect profiles. However, adherence levels remain low in adult psychiatric patients.
Health Belief Models
Health belief models have been employed to explain adherence to a variety of preventive and treatment regimens, including psychotropic medications. Originally conceptualized by Rosenstock (1974) and refined by Fishbein and Ajzen (1975) and Ajzen and Fishbein (1980), the model has been adapted to explain aspects of psychotropic nonadherence (Perkins, 2002). The health belief model posits that patients actively evaluate the costs and benefits of treatment, their susceptibility to symptom relapse, and the extent to which negative consequences are associated with relapse. This model suggests that patients are active participants in making treatment decisions, weighing the advantages and disadvantages of their treatment options.
Models of Subjective Well-Being
Subjective well-being models suggest that patients’ perceived quality of life is a combination of their subjective experience of medication plus the per- ceived advantages of symptom relief. This model goes beyond the presence or absence of side effects per se to account for patients’ subjective experi- ence and their attitudes toward medication. Instruments such as the Drug Attitude Inventory (Hogan, Awad, & Eastwood, 1983; Voruganti & Awad, 2002) and the Subjective Well-Being under Neuroleptics Scale (Naber, 1995) were created to examine subjective well-being factors systematically. These authors found that measures of subjective well-being correlated significantly with patient adherence to psychotropic medications.
The following section presents the criteria for selection of the system- atic reviews and the results of the adherence enhancement interventions examined. As will be demonstrated, the empirical work on adherence has not been linked closely with theories about why resistance to psychotropic medications is so high. The result is a body of loosely connected studies that provide little direction for practitioners who hope to assist patients with medication management difficulties. Recommendations for tightening knowledge gaps are provided in an effort to steer research efforts in a more cohesive direction.
CRITERIA FOR STUDY SELECTION
The search for systematic reviews cast a wide net, consistent with Cook, Mulrow, and Haynes’ (1997) emphasis on avoiding sampling bias. Two major databases were used: PsychInfo (1967 to present) and Medline (no
516 L. Townsend
restrictions). These databases were chosen because of their tendency to capture studies from a wide range of disciplines. Selection for inclusion in the review sample was based on the following criteria:
� Articles contained a systematic review or meta-analysis of adherence in- tervention research.
� The primary goal of the interventions was to increase adherence to psy- chotropic medication.
� Reviews examined randomized, controlled trials or trials including one or more comparison groups.
� Interventions were conducted with adults diagnosed with severe mental illness.
Sampling excluded primary care studies dealing with physical syndromes and studies of substance abuse treatment. Eight systematic reviews/meta- analyses were included in the initial sample (Dolder, Lacro et al., 2003; Gray, Wykes, & Gournay, 2002; Macdonald, Garg, & Haynes, 2002; Nose, Barbui, Gray, & Tansella, 2003; Pampallona, Bollini, Tibaldi, Kupelnick, & Munizza, 2002; Sajatovic, Davies, & Hrouda, 2004; Vergouwen, Bakker, Katon, Verheij, & Koerselman, 2003; Zygmunt, Olfson, Boyer, & Mechanic, 2002). Table 1 provides a summary of the systematic reviews and their findings.
RESULTS OF SYSTEMATIC REVIEWS
Numerous interventions have been devised to improve patients’ willingness to adhere to pharmacological treatment. Interventions found in the literature subsume a variety of clinical orientations, including psychoeducation, be- havioral intervention, cognitive-behavioral techniques, family supports, case management, and motivational interviewing. The following section sum- marizes the conclusions of eight systematic reviews according to the two criteria outlined earlier: conceptual adequacy and quality of research design. Additional consideration is given to the studies’ ability to inform preliminary practice guidelines according to the criteria outlined by Proctor and Rosen (2000): relationship of findings to outcome targets, the array of interventions available for practitioners, criteria for practitioner choice of interventions, and delineation of gaps in empirical knowledge and limitations of the research.
Conceptual Adequacy
In examining the adequacy of the adherence definitions used in the stud- ies, four factors were identified that went unaddressed in the interventions used. These factors were: lack of consistency in definitions of adherence,
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patients’ own self-definitions of adherence, environmental impediments to affording and obtaining medication, and cultural influences on beliefs about medication.
ADHERENCE DEFINITIONS
Among the 164 primary studies included in the systematic reviews, research designs differed substantially in their definitions of adherence. Some studies conceptualized adherence as a binary outcome (‘‘good’’ vs. ‘‘poor’’; Razali & Yahya, 1995). Other studies relied on bottle-monitoring devices, pill counts, self-report, clinician report, urine assays, or serum levels. Pampallona et al. (2002) found that some studies incorporated a variety of measures into a composite compliance index. Considerable debate remains in the literature regarding the reliability and validity of adherence measurements. Lack of a consistent operationalization of adherence renders it difficult to describe ac- tual levels of adherence and inhibits cross-study comparisons of intervention outcomes.
Of additional concern is the absence of patient-defined adherence con- cepts. Not only is it important to establish valid measures of adherence; it is vital to determine how patients view adherence. It is possible that the construct of adherence is defined differently by patients than by researchers and practitioners. No work was uncovered that links patients’ definition of adherence with interventions designed to enhance it. This is an important conceptual gap, given that interventions are aimed at enhancing client ad- herence; their definition of adherence directly impacts intervention success.
TARGET OUTCOMES
Furthermore, findings are not organized separately according to adherence targets; some studies measured adherence to medication, whereas others examined clinic appointment or psychotherapy attendance. Although the pri- mary aim was to include studies examining adherence to medication, many reviews combined studies assessing clinic appointment or psychotherapy attendance along with adherence to medication.
ENVIRONMENTAL BARRIERS TO ADHERENCE
Environmental barriers to adherence were not incorporated into the majority of the adherence enhancement studies: None of the research examined in this review systematically examined environmental barriers to obtaining medication. Only one review (Sajatovic et al., 2004) mentioned the impact of factors such as inadequate housing, lack of funds, or transportation issues on adherence. These limitations may be formidable obstacles to adherence,
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especially in populations of people with severe and persistent mental ill- ness who are disabled, of lower socioeconomic status, isolated from social supports, or uninsured.
CULTURAL BARRIERS TO ADHERENCE
The majority of studies reviewed did not include culture, ethnicity, or reli- gious practice as a factor influencing their interventions. Only one primary study addressed the impact of culture on adherence. In their sample of Chi- nese families of patients with schizophrenia, Xiang, Ran, & Li (1994) found that significant stigma must be overcome before implementing adherence interventions with patients and family members. The role of culture in this population plays an important part in the acknowledgement of mental illness and the corresponding need for treatment. It is likely that other cultures may hold strong beliefs about the etiology of mental illness, differential willingness to acknowledge and seek treatment for mental disorders, and offer differing degrees of support to patients. These features must be taken into account when designing interventions in this country, as there are many individuals who come from diverse cultural and ethnic heritages.
Quality of Research Methodology
In reviewing the research designs of the intervention studies summarized in the systematic reviews, six problems with study design were identified: (a) lack of a ‘‘gold standard’’ measure of adherence, (b) between-study differences in adherence outcome targets, (c) heterogeneity of study samples, (d) lack of consistency in the design of the interventions themselves, (e) lack of adequate statistical power to detect intervention effects, and (f) lack of statistical control for the effects of polypharmacy. These issues are discussed below.
ADHERENCE MEASURES
Much of the foregoing discussion regarding conceptually adequate defini- tions of adherence is also relevant to evaluating the methodology employed in the studies reviewed. Not only is adherence defined poorly as a construct; it has been measured poorly as a target outcome. The intervention studies reviewed showed little standardization of adherence measures, employing a variety of assessments with little comparability between them. As discussed previously, adherence was measured in a variety of ways, including pill counts, self-report, blood levels, pharmacy refill records, and electronic bottle monitoring. This presented difficulties for those authors who attempted to conduct meta-analyses but converted their studies to systematic reviews due to the inability to standardize adherence results (Pampallona et al., 2002;
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Vergouwen et al., 2003). These differences in measurement render it difficult to integrate the results of studies with markedly different outcome variables.
TARGET ADHERENCE OUTCOMES
A similar difficulty presented itself regarding the issue of desired target outcomes of adherence. Just as with adherence measurement, the lack of consistency in desired target outcomes led to a lack of comparability be- tween intervention studies. In the studies included here, target outcomes included adherence to medication, clinic appointments, and psychotherapy. This makes it difficult to generalize results across studies. It is likely that patients may have different likelihoods of adhering to medication than for attending psychotherapy appointments, although the two are likely to be related. Nonadherence to medication may influence patients’ willingness to visit their doctors, further complicating assessment of these target outcomes. This necessitates study designs that are capable of separating the overlapping effects of medication non-adherence from appointment non-adherence.
SAMPLING
Among the studies compared, lack of consistency in patient sampling pre- vented direct comparability between studies. Across studies, there was signif- icant variability in the types of patients who participated in the intervention protocols. Differences existed at the diagnostic level, ranging from studies including only patients with psychotic spectrum disorders (Nose et al. (2003) to studies including all Axis I diagnoses (Cramer & Rosenheck, 1998). Patients also differed in levels of symptomatology, from highly symptomatic (Razali & Yahla, 1995) to ‘‘clinically stable’’ (Macpherson, Jerrom, & Hughes, 1996).
Of utmost importance to studies’ ability to detect significant adherence differences, participants also differed in their level of initial adherence be- havior, from low (Razali & Yahla, 1995) to high adherence at the time of study enrollment (Atkinson, Coia, Gilmour, & Harper, 1996). Floor effects may not be significant impediments to research results, allowing room to detect intervention effects; however, ceiling effects make it difficult to draw conclusions about the relative effectiveness of interventions when comparing experimental and control groups that have little room for improvement in adherence (Shadish, Cook, and Campbell, 2002).
VARIABILITY IN INTERVENTION DESIGNS
Lack of consistency in the type of interventions used to enhance adherence influenced the ability to compare studies with one another. Intervention designs differed both across theoretical orientations (as with psychoanalytic vs. cognitive-behavioral approaches, for example) and within theoretical
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orientations (e.g., differing levels of complexity and intensity for cognitive- behavioral interventions). The interventions reviewed here differed substan- tially both across and within theoretical orientations. A variety of techniques were employed, including psychoeducation, case management, cognitive- behavioral strategies, and motivational interviewing. A single intervention often incorporated components from a variety of theoretical orientations, such as combining psychoeducation and cognitive-behavioral techniques (Peveler, George, Kinmonth, Campbell, & Thompson, 1999).
An example of variability within theoretical orientation is represented by cognitive-behavioral interventions that varied substantially in their level of complexity. They ranged from mostly behavioral (Eckman, Liberman, & Phipps, 1990) to more thought-based cognitive restructuring (Lecompte & Pelc, 1996). Intervention protocols also differed in terms of the number and intensity of sessions, length of follow-up, and in type of provider who administered the intervention. These variations make it difficult to compare studies between and within theoretical orientations.
LOW STATISTICAL POWER
One of the most serious difficulties with the intervention studies was the lack of attention to statistical power. The number of participants across studies ranged from 14 (Altamura & Mauri, 1985) to 4,052 (Melfi et al., 1998). Although many of the primary studies reviewed enrolled at least 100 partici- pants, a number of them drew conclusions from significantly fewer patients. This skews the population of studies from which conclusions can be drawn: Underpowered studies are unlikely to detect even robust effects, whereas studies with thousands of subjects are likely to detect results that may be clinically insignificant. These power differences contribute to the difficulty in drawing conclusions about the efficacy of adherence interventions.
POLYPHARMACY
A surprising finding of this review was the failure of researchers to address the issue of polypharmacy, which refers to the simultaneous prescription of several medications to treat an individual. Over the past several decades, prescription of two or more concomitant psychotropic medications has be- come the norm rather than the exception (Ananth, Parameswaran, & Gu- natilake, 2004; Frye et al., 2000). None of the studies addressed whether adherence differs for patients who receive different numbers of prescriptions. In clinical practice, patients may take a mood stabilizer, an antipsychotic, and an anxiolytic according to symptom-based rather than syndrome-based prescribing algorithms. Each of these agents has different side effect profiles and the propensity to generate different patient reactions regarding their acceptability.
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To summarize, adherence intervention studies to date suffer from methodological flaws that render it difficult for consumers of research to decide which interventions are most efficacious in helping patients adhere to treatment. There is no agreed-upon gold standard for measuring adherence, a variety of adherence targets that may benefit from differing interventions, and a lack of consistency in the intervention protocols presented in the literature. Many studies are underpowered and combine a variety of Axis I disorders without examining whether interventions have differential impact based on type of mental health disorder.
PROCTOR AND ROSEN’S CRITERIA FOR PRACTICE GUIDELINES
Proctor and Rosen (2000) devised a rubric for creating practice guidelines that evaluates the usefulness of data for incorporation into practice. They recommend that practice guidelines in social work address the following areas: specification of outcome targets, presentation of a comprehensive intervention array, criteria for practitioner choice of interventions, and delin- eation of gaps in empirical knowledge and limitations of research.
Currently, there is little evidence to support development of practice guidelines for adherence enhancement in adults with severe mental illness, even at a preliminary level. The intervention protocols examined are too highly variable to be implemented with fidelity by practitioners, and it re- mains to be seen whether interventions with a high level of complexity can be distilled into a smaller number of cost-effective components.
Specification of Outcome Targets
Proctor and Rosen’s first guideline requires that outcome targets be clearly specified. There is little consistent information provided by the studies re- viewed that allow results to be synthesized into a format usable by practition- ers. This first practice guideline criterion cannot be met due to inconsistencies in existing research designs: Practitioners will be unable to connect clear out- come targets with specific interventions designed to achieve those outcomes without studies that link specific interventions to specific outcomes.
Comprehensive Intervention Array and Guidelines for Practitioner Choice
Proctor and Rosen’s second and third criteria require that practitioners be able to present a comprehensive intervention array to their clients and that there are specific standards that guide practitioners as they choose among
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the interventions available to them. As it stands now, intervention protocols are diffuse and non-standardized, making it difficult to organize them in relation to outcomes desired by clients and practitioners. This also renders it difficult to construct specific criteria that can be used to guide choices of one intervention over another.
Research Limitations
Proctor and Rosen’s fourth criterion is that practice guidelines delineate exist- ing gaps in empirical knowledge and articulate the limitations of the research that informs these guidelines. For practice guidelines to be usable for practi- tioners, they must specify recommendations for action while acknowledging the limitations in knowledge or restrictions on applicability to particular client populations or circumstances. The underlying assumption is that a substantial enough body of knowledge exists to inform practice decisions. Regarding adherence enhancement, the gaps in existing knowledge are wider than what is known and necessitate a reconceptualization of the types of studies that will provide the information practitioners need to made educated decisions about enhancing client adherence.
IMPLICATIONS FOR SOCIAL WORK PRACTICE: CHARACTERISTICS OF SUCCESSFUL INTERVENTIONS
This section presents findings gathered from the systematic reviews of the adherence literature that may serve to guide future research efforts; however, these findings are presented with the caveat that interventions that hold promise should be subjected to more rigorous examination before solid conclusions can be drawn about their efficacy.
Overall, psychoeducation without cognitive or behavioral components was unsupported by the reviews. The majority of studies demonstrated no significant difference between psychoeducation groups and controls. One qualification is that studies involving complex approaches, such as combina- tions of psychoeducation, collaborative treatment, and cognitive techniques, tended to improve adherence compared to controls (Dolder et al., 2003).
Tentative support across studies was shown for cognitive-behavioral interventions. Cognitive-behavioral techniques that were supported included those employing coping strategies such as negative thought replacement (Robinson et al., 1995) and collaborative treatment with cognitive and mo- tivational interviewing components (Spooren, Van Heeringen, & Jannes, 1998). Although only evaluated by one group, compliance therapy (Kemp, Hayward, Applewaithe, Everitt, & David, 1996) received consistent support. This intervention involves a collaborative alliance between provider and patient, addressing illness history and symptoms, exploring ambivalence
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toward diagnosis and treatment, and motivational interviewing to address treatment barriers. Of particular significance is the discussion of perceived stigma and its impact on patients’ perceptions of treatment. These findings are consistent with the health belief model put forth by Fishbein and Ajzen (1975) and Ajzen and Fishbein (1980), in which individual attitudes are shaped in part by subjective norms held by important others in their social environment. Among the models presented previously, the health belief model is supported most consistently by empirical evidence and may provide a useful framework for future research on adherence.
Despite the inconclusive results across studies, a review of the studies that showed promise revealed several consistent themes that appear to be associated with increased adherence to medications. These themes may be of use to social workers in their daily practice with clients who are struggling with taking their medication as prescribed.
Collaborative Care
One of the consistent commonalities among the cognitive-behavioral tech- niques employed was the idea of collaboration between the patient and provider. Each of the successful cognitive-behavioral interventions incorpo- rated patient perspectives on their illness and symptoms and the impact of psychotropic medication. Stigma was often addressed, with providers helping patients to reframe feelings of shame and strive for stability with the aid of medication. Motivational interviewing, a technique widely used in substance abuse treatment (Miller & Rollnick, 1991) was employed, ac- knowledging the importance of patients’ conceptions of their difficulties and possible resolutions. The concept of collaboration between provider and patient is consistent with social work’s code of ethics, which requires social workers to promote self-determination in treatment given that a patient’s safety is not in jeopardy (Reamer, 2002). This approach also coincides with the health belief model (Fishbein & Ajzen, 1975; Ajzen & Fishbein, 1980), which posits that individuals take an active role in weighing the advantages and disadvantages of treatment recommendations.
Consistent Follow-Up
A second common characteristic of successful interventions was consistent follow-up on the part of providers to ensure appointment attendance and early identification of difficulties with treatment. This may represent a vital element of ongoing care for people with severe mental illness, as their cognitive abilities may wax and wane depending on symptom severity and environmental barriers such as difficulties obtaining transportation or main- taining health insurance benefits may hinder adherence.
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Comprehensive Care
A third characteristic of successful interventions was their level of complexity. More comprehensive interventions that involved patients, caregivers, psychi- atrists, nurses, and psychotherapists tended to elicit higher levels of adher- ence to treatment. Given the greater treatment needs of people with severe mental illness, it is likely that better outcomes will be achieved when patients are surrounded by a network of caring professionals and significant others who monitor their progress in a collaborative manner. Floersch’s concept (2002, pg. 31) of the ‘‘social grid of medication management’’ highlights the impact of provider networks on patient outcomes, noting that social supports impact patient well-being and goal achievement.
Psychoeducation
Although interventions employing only psychoeducation were largely un- successful in eliciting better adherence to treatment, there is little basis to forgo education altogether. In fact, psychoeducation was incorporated into many of the cognitive-behavioral interventions that elicited greater adherence outcomes. Educating clients about the types of treatments that are available and their relative effectiveness is part of responsible, evidence-based practice (Gambrill, 1997) and establishes a foundation for treatment. Additionally, patients are unlikely to benefit from the strategies learned in cognitive- behavioral treatment if they lack a fundamental understanding of their ill- nesses, relapse triggers, and the role that medication plays in maintaining stability.
CONCLUSION
The state of the literature points not to development of practice guidelines but to suggestions for methodological changes that must be made to generate guidelines for adherence interventions. Specifically, studies must become more rigorous in their design and implementation (e.g., conducting power analyses prior to recruiting study participants and controlling for diagnosis, symptom severity, and polypharmacy). Increased standardization is needed; some studies are already manualized (Kluger & Karras, 1983; Hogarty, 2002), whereas others are non-standardized across intervention sites (Spooren et al., 1998). Future interventions that employ complex strategies informed by multiple theoretical orientations should have the statistical power necessary to partial out main effects, interactions, and multiplicative effects of the interventions on adherence outcomes. These studies must clarify the specific intervention components examined and be explicit about how the interven- tions were conducted. Most important, target outcomes must be linked to
526 L. Townsend
specific interventions. For example, is cognitive-behavioral therapy useful for both medication adherence and appointment attendance, or are different interventions needed? Are these effects moderated by client population?
This review highlights a series of important research questions:
� Does intervention effectiveness differ by diagnostic category? (i.e., do people with schizophrenia derive different benefits from adherence in- terventions than people with depression or bipolar disorder?)
� Does symptom severity predict the level of benefit patients receive from an adherence intervention?
� Are there fundamental components of multi-faceted interventions that gen- erate greater adherence? Can interventions be pared down so that they maintain effectiveness while consuming fewer practitioner and monetary resources?
� What is the optimal length of an adherence intervention? � What client factors predict response to adherence intervention? Are inter-
ventions moderated or mediated by particular client characteristics? � How do clients themselves define adequate adherence?
Many of these questions are fundamental to our understanding of how adherence interventions work (and how they fail). Until these questions can be answered in a scientifically rigorous way, practitioners are left with enor- mous gaps in their knowledge about which interventions may be effective for clients. As the number of studies with proper standardization and controls increases, further systematic reviews can be conducted, organizing interven- tions according to theoretical orientation, diagnostic population, symptom severity, or other relevant predictors. Only then can systematic reviews be used to create practice guidelines that provide definitive information to assist practitioners in making decisions about which interventions are appropriate for their clients.
Presently, clinical practice can incorporate the elements of interven- tions that have shown promise in the empirical studies conducted thus far. Common elements of successful interventions include cognitive-behavioral techniques that elicit patients’ own perspectives on medication; a collab- orative stance between patients and providers that emphasizes patients’ decision-making abilities and freedom of choice; a comprehensive treatment approach that educates patients about the advantages and disadvantages of medication and skills to enhance their adherence; and consistent follow- up so that providers have early awareness of problems their patients may experience with treatment. These elements common to successful adherence enhancement and improved patient outcomes are not only starting points for further research but can be implemented readily by social workers and other professionals whose work it is to help patients maintain stability and remain active participants in their treatment.
Adherence Enhancement 527
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