Velligan Dawn I, Weiden Peter J, Sajatovic Martha, Scott Jan, Carpenter Daniel, Ross Ruth, Docherty John P
University of Texas Health Science Center, San Antonio, TX, USA.
J Clin Psychiatry. 2009;70 Suppl 4:1-46; quiz 47-8.
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.
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.
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.
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.
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.
Adherence problems are complex and multidetermined. The experts recommended customized interventions focused on the underlying causes.
对药物治疗依从性差会给精神疾病患者带来灾难性后果。本项目的目标是制定相关建议，以解决依从性问题，改善患者预后。
编辑们确定了有关严重精神疾病中药物依从性问题的重要主题和问题，而这些问题在文献中并未得到充分探讨。开展了一项包含39个问题（521个选项）的调查，内容涉及不依从的定义、精神分裂症和双相情感障碍中依从性问题的程度、不依从的风险因素、评估方法以及针对特定类型依从性问题的干预措施。该调查发送给了48位专家，其中41位（85%）完成了调查。文献综述和调查结果被用于制定评估和改善严重精神疾病患者依从性的建议。
评估依从性：专家们认可未服用药物的百分比作为定义依从性的首选方法，对于双相情感障碍和精神分裂症，服用80%或更多的药物被认可为依从性的合适临界值。虽然自我报告和医生报告是临床环境中评估依从性最常用的方法，但它们往往不准确，可能会低估不依从情况。专家们建议，如果可能的话，临床医生还应使用更客观的措施（如药丸计数、药房记录，以及适当时的血清水平，如用于锂盐的检测）。使用经过验证的自我报告量表可能有助于提高准确性。
大多数专家认为，在他们的临床实践中，精神分裂症或双相情感障碍的普通患者仅服用了规定药物的51% - 70%。
专家们认可洞察力差和对疾病缺乏认识、与特定副作用相关的痛苦或对副作用的普遍恐惧、持续症状下疗效不足以及认为不再需要药物是导致精神分裂症和双相情感障碍依从性问题的最重要因素。专家们认为体重增加是一种很可能导致精神分裂症和双相情感障碍患者依从性问题的副作用；镇静作用被认为在双相情感障碍中比在精神分裂症中对依从性问题的影响更大。专家们将精神分裂症中持续的阳性或阴性症状以及双相情感障碍中持续的夸大和躁狂症状评为这些疾病中依从性问题的最重要症状因素。
识别可能导致患者依从性问题的具体因素很重要，以便针对这些问题定制干预措施。可能涉及多个问题，需要综合多种干预措施。
依从性问题复杂且由多种因素决定。专家们建议针对潜在原因进行定制化干预。
