Zeber John E, Copeland Laurel A, Good Chester B, Fine Michael J, Bauer Mark S, Kilbourne Amy M
Veterans Affairs HSR&D: South Texas Veterans Health Care System (VERDICT), University of Texas Health Science Center at San Antonio, Department of Psychiatry, San Antonio, TX 78229-4404, United States.
J Affect Disord. 2008 Apr;107(1-3):53-62. doi: 10.1016/j.jad.2007.07.026. Epub 2007 Sep 5.
Despite the dissemination of practice guidelines for bipolar disorder, outcomes remain suboptimal, largely due to poor treatment adherence. The episodic nature of bipolar disorder disrupts appropriate patient-provider dynamics, interfering with appropriate care. Maintaining a beneficial therapeutic alliance with providers is one important strategy for improving adherence. We examine the association between adherence and therapeutic environment perceptions among veterans with bipolar disorder.
Participants were recruited from the Continuous Improvement for Veterans in Care--Mood Disorders (CIVIC-MD) study (N=435). Individual items and a summary score from the Health Care Climate Questionnaire (HCCQ) for bipolar disorder solicited patient evaluations of their therapeutic environment. Multivariable logistic analyses examined the association between therapeutic alliance and two measures of adherence (missed medication days and intrapersonal barriers), adjusting for relevant patient characteristics.
Adherence difficulty was reported on both measures, with substantial differences between perceived barriers and actual medication behavior. Significantly fewer minority veterans endorsed good adherence than white patients (59% versus 77%), although no ethnic differences were noted in therapeutic environment perceptions. Multivariable results indicated that positive therapeutic alliance was associated with better adherence (HCCQ effect sizes 13-20%). Notably, patients reporting providers encouraged "staying in regular contact" were more likely to be adherent, as were patients whose "providers regularly review their progress".
Generalizability from observational study; adherence defined by cross-sectional patient self-report.
The observed association between medication adherence and therapeutic alliance with bipolar treatment supports intervention efforts to strengthen the patient-provider relationship, a bond likely to yield positive clinical outcomes.
尽管双相情感障碍的实践指南已得到广泛传播，但治疗效果仍不尽人意，这主要是由于治疗依从性差所致。双相情感障碍的发作性特征破坏了医患之间的正常互动，干扰了适当的治疗。与医护人员保持良好的治疗联盟是提高依从性的一项重要策略。我们研究了双相情感障碍退伍军人的依从性与对治疗环境的认知之间的关联。
参与者来自退伍军人护理持续改进——情绪障碍（CIVIC-MD）研究（N = 435）。双相情感障碍的医疗保健氛围问卷（HCCQ）中的单项条目和汇总得分用于收集患者对其治疗环境的评价。多变量逻辑分析研究了治疗联盟与两种依从性指标（漏服药物天数和个人障碍）之间的关联，并对相关患者特征进行了调整。
两项指标均显示存在依从性困难，感知障碍与实际用药行为之间存在显著差异。认可良好依从性的少数族裔退伍军人明显少于白人患者（59% 对 77%），尽管在治疗环境认知方面未发现种族差异。多变量结果表明，积极的治疗联盟与更好的依从性相关（HCCQ效应大小为13 - 20%）。值得注意的是，表示医护人员鼓励“保持定期联系”的患者更有可能依从，“医护人员定期审查其进展情况”的患者也是如此。
观察性研究的可推广性；依从性由横断面患者自我报告定义。
观察到的双相情感障碍治疗中药物依从性与治疗联盟之间的关联支持了加强医患关系的干预措施，这种关系可能会产生积极的临床结果。
