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, MS # 7792, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA.
J Psychiatr Pract. 2010 Jan;16(1):34-45. doi: 10.1097/01.pra.0000367776.96012.ca.
Poor adherence to medication treatment can have devastating consequences for patients with serious mental illness. The literature review and recommendations in this article concerning assessment of adherence are reprinted from The Expert Consensus Guideline Series: Adherence Problems in Patients with Serious and Persistent Mental Illness, published in 2009. The expert consensus survey contained 39 questions (521 options) that asked 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. When evaluating adherence, the experts considered it important to assess both behavior and attitude, although they considered actual behavior most important. They also noted the importance of distinguishing patients who are not willing to take medication from those who are willing but not able to take their medication as prescribed due to forgetfulness, misunderstanding of instructions, or financial or environmental problems, since this will affect the type of intervention needed. Although self- and physician report are most commonly used to clinically assess adherence, they are often inaccurate and may underestimate nonadherence. The experts believe that more accurate information will be obtained by asking about any problems patients are having or anticipate having taking medication rather than if they have been taking their medication; They also recommended speaking with family or caregivers, if the patient gives permission, as well as using more objective measures (e.g., pill counts, pharmacy records, smart pill containers if available, and, when appropriate, medication plasma levels). Use of a validated self-report scale may also help improve accuracy. For patients who appear adherent to medication, the experts recommended monthly assessments for adherence, with additional assessments if there is a noticeable symptomatic change. If there is concern about adherence, they recommended more frequent (e.g., weekly) assessments. The article concludes with suggestions for clinical interview techniques for assessing adherence.
对患有严重精神疾病的患者而言，药物治疗依从性差可能会产生灾难性后果。本文中有关依从性评估的文献综述和建议转载自2009年出版的《专家共识指南系列：严重和持续性精神疾病患者的依从性问题》。专家共识调查包含39个问题（521个选项），涉及非依从性的定义、精神分裂症和双相情感障碍中依从性问题的程度、非依从性的风险因素、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。在评估依从性时，专家们认为评估行为和态度都很重要，不过他们认为实际行为最为重要。他们还指出，区分不愿服药的患者和因遗忘、误解用药说明或经济或环境问题而愿意服药但无法按规定服药的患者很重要，因为这会影响所需干预措施的类型。虽然自我报告和医生报告是临床评估依从性最常用的方法，但它们往往不准确，可能会低估非依从性情况。专家们认为，询问患者在服药过程中遇到或预计会遇到的任何问题，而不是询问他们是否一直在服药，能获得更准确的信息；他们还建议，如果患者允许，与家人或护理人员交谈，同时使用更客观的措施（如清点药片、药房记录、如有可用的智能药盒，以及在适当情况下检测药物血浆水平）。使用经过验证的自我报告量表也可能有助于提高准确性。对于看似依从药物治疗的患者，专家们建议每月评估一次依从性，如果症状有明显变化则进行额外评估。如果对依从性存在担忧，他们建议更频繁（如每周）进行评估。文章最后给出了评估依从性的临床访谈技巧建议。
