Journal Critique

IMPROVING TREATMENT ADHERENCE IN BIPOLAR DISORDER: A Review of Current Psychosocial Treatment Efficacy and Recommendations for Future Treatment Development

SUMMARY
         Bipolar disorders I and II are chronic and severe mental illnesses present in 3.9 percent of the general population. It is the sixth leading cause of disability worldwide in those ages 15 to 44 and costs those affected more than $17,000 annually for treatment. Given that bipolar disorder has a high rate of relapse, it is important to study if treatment adherence, or nonadherence, could be one reason.
         Treatment adherence may be difficult to study because it is often defined differently. Therefore, there are several ways of categorizing nonadherence behaviors: full nonadherence, selective nonadherence, intermittent adherence, late adherence or nonadherence, abuse, and behavioral adherence. The latter is most important in this study because it is more complex than the others and is apparently treated more with psychosocial treatments, which are only recently accepted.
         Measures of adherence are divided broadly into objective and subjective categories. Objective adherence is measured by records of medication and appointments, while subjective adherence is measured by self-reports of patients. Subjective measurements are deemed questionable; however, other participants in the patient’s life often confirm the self-reports.  Recently, researchers have combined strategies of assessment in an attempt to improve and verify data on adherence. These studies may give a better idea of adherence behaviors, but will also make reports more difficult to interpret.
         This study resulted in 14 clinical trials that met criteria: (a) random assignment to conditions, (b) inclusion of a psychosocial treatment in at least one treatment arm, (c) report of at least one medication-related adherence outcome. Only two of the selected studies tested an intervention primarily designed to improve bipolar treatment adherence, but reviewing the findings from these trials can be helpful for designing psychosocial interventions in the future to improve bipolar adherence specifically.
         In cognitive-behavioral interventions, findings suggested that the addition of these could possibly enhance treatment adherence. In medication adherence, there were mixed findings. Patients in the experimental condition were more likely to be rated as adherent. There was also some support for the idea that adjunctive cognitive-behavioral interventions may enhance treatment adherence. However, further studies failed to show a connection between cognitive-behavioral interventions and enhanced medication adherence. In behavioral adherence, the examination of these indices proved more inconsistency in cognitive-behavioral treatment (CBT). In these trials, patients attended roughly ¾ of the sessions offered, but more patients completed CBT than just the medication monitoring. In psychoeducation, three studies showed that psychoeducation may improve treatment adherence, while two did not show much benefits. In medication adherence, patients who attended an education program were less likely to report missed medication than patients in wait-list control.
         It is important to note that the prior conclusions in regards to the utility of psychosocial intervention for increasing adherence in bipolar disorder would be premature. However, there are some promising strategies that would benefit from increased attention. Studies that directly targeted knowledge and improved attitudes toward lithium predicted medication adherence. Though medication adherence was studied, interventions varied in proportion of time in this study. One benefit of these interventions is that they may be more cost-effective. Positive results for treatment adherence have been obtained in studies using low-intensity interventions in other populations. Although it isn’t clear, the inclusion of someone close in psychotherapy needs continued attention. Some studies suggest that family interventions may approve medication adherence. There is some preliminary evidence that the effects of family-focused therapy (FFT) on medication adherence may last longer, as there was a significant but small effect of improved adherence in FFT versus crisis management (CM) at about 1-year posttreatment. There was little evidence that the previously mentioned interventions improved behavioral adherence specifically. A study indicated that bipolar patients with a comorbid substance use problem were retained in treatment at about twice the rate in the CBT condition compared with the medication-monitoring-alone condition. However, the study reported more drop out in the PE condition compared with the control condition. This may suggest problems with treatment acceptability.
         One of the difficulties with conducting bipolar treatment studies is dealing with patient heterogeneity. When creating a bipolar adherence program, important decisions need to be made that include a variety of possible inclusion/exclusion criteria, including diagnostic subtypes, episode status at study entry, type of mood episode, treatment setting, and potential comorbidities. Although it is preferable to reduce heterogeneity as much as possible when conducting efficacy trials, the balance of internal and external validity is important. There are many of possible differences between patients with bipolar I versus II disorder as well as differences in their respective treatment. Bipolar I patients tend to have higher nonadherence rates. Also, patients receiving acute treatment in hospital settings are more likely to be nonadherent and relapse after discharge, which puts them in a good position for adherence interventions. However, outpatients with bipolar disorder seem to react better to adherence interventions. Therefore, their status may show change better over time. For example, studies found that adherence measures had positive effects in initially remitted patients, but their advantages showed only over longer term follow-up in a mood episode at study entry. Also, adherence interventions may need to contain certain elements for addressing mania versus depression, considering that preferred treatments for different phases of bipolar episodes vary. So, the decision to study patients with one type of mood episode should be decided by what the particular intervention’s aims are that are being tested. Finally, since there is a high rate of comorbidity (anxiety disorders) in bipolar patients, which seems to be dominant, exclusion criteria that is too restrictive would not be productive in producing an adherence program that is generalizable to the majority of the patient population.
         Another important issue of past studies was the diversity of comparison conditions used to assess psychosocial treatment efficacy in bipolar patients. Most bipolar psychosocial interventions have been compared to some form of TAU, which was usually pharmacotherapy alone. Regardless of whether or not a patient is assigned to the experimental interventions, all patients would be receiving a primary treatment that probably includes pharmacotherapy alone. Depending on what the proposed adherence program desires to achieve, patients may also be required to receive some form of behavioral treatment, especially if they are experiencing depression. Therefore, the usual treatment may also prove a useful setting for testing bipolar adherence programs. However, if the intervention is designed to target a specific type of treatment, than it may be necessary to provide the primary treatment as part of the study. This inclusion would better isolate the effects of the intervention on this specific aspect of a patient’s regimen. It is important to point out that a study designed to contain only primary treatments would not show enough evidence that any improvements in adherence in the study could be credited to the adjunctive adherence intervention itself. There is a possibility that increases in adherence could only be a product of the additional exposure to professional contact by patients in the intervention if the comparison group were to receive no additional intervention. Therefore, to compensate for the nonunique aspects of the intervention, patients assigned to the intervention should probably be compared with a group of patients receiving additional components. Also, in two of the trials that specifically tested adherence programs, both were employed in conjunction with pharmacotherapy but did not control for the extra treatment provided. Therefore, more complex programs will be needed in future research.
         As previously mentioned, defining and measuring treatment adherence can be complicated, especially when bipolar patients may be receiving a diversity of treatments. It has been demonstrated that beneficial effects could be found using self-report, clinician-rated, and objective indices of adherence. There are newer technologies such as ecological momentary assessment that may help increase accuracy in assessment strategies and could provide more detailed information about factors that may influence adherence behaviors. Importantly, in every trial examined, the primary focus was on medication adherence specifically. There was also an attempt to examine the potential effects on behavioral adherence but this information has not been consistently reported. Future studies of bipolar adherence programs must include more specific measures of behavioral adherence. One such measure is the newly developed measure called the Psychosocial Treatment Compliance Scale. Finally, the complex relationship among adherence behaviors, symptomatic improvement, and other clinical variables is an issue that is particularly relevant to psychosocial trials for bipolar disorder.
         In previous observations, the efficacy of currently available treatments for bipolar patients seems to decrease when these same treatments are delivered in the community. One explanation may be that some important aspects of bipolar disorder are not being adequately addressed in the existing treatment literature. Two important aspects of bipolar disorder that require careful consideration when developing and testing psychosocial interventions are comorbid substance use disorders and bipolar depression.
         Most of the studies reviewed excluded patients with comorbid substance use disorders (SUD). However, these two disorders often occur together. Many factors have been shown to relate comorbid SUDs and bipolar patients. Also, the most substantial predictor of nonadherence in bipolar patients is the presence of a comorbid SUD. Considering the frequency of comorbid SUDs in bipolar patients, there are very few studies of psychosocial treatments for bipolar substance abusers specifically.
         Another aspect of bipolar disorder that is absent from many psychosocial interventions is bipolar depression, a depressive phase of the illness. Of the trial reviewed previously, depressed patients were underrepresented. However, the relevance of treatment adherence to bipolar depression is significant, as it is associated with functional impairment and creates substantial risk for suicide. If it is left untreated, bipolar depression can raise morbidity and mortality.
         It is incredibly important to develop and test new treatment adherence programs for bipolar adherence of many types. These strategies are worthy of expanding, but there is not much evidence of the efficacy of existing treatment adherence strategies and the study of behavioral (in contrast to medication) adherence in bipolar patients is only in its early stages. Therefore, there is much need for future research focusing on the development of new, evidence-based programs that target a variety of treatment-related adherence behaviors and are based on interventions that show the most progress. These programs are those that will become the most important element to connecting efficacy and effectiveness of treatments for bipolar disorder.




CRITIQUE
         This journal involves mental illness. Learning about it, learning how to improve treatment, and, briefly, a way to make treatment easier on finances.  It used both control and experimental groups to identify differences made in adherence by education and support in medicine, counseling, and hospitalization. These studies pertain to what we are studying now in a few ways: (a) persons with mental illness often need the aid of social workers, (b) studying a mental illness increases awareness and knowledge, which cuts down on stereotyping and prejudice, and (c) shows how the ecological system is affected by mental illness.
         In this journal, it stated that treatment for bipolar disorder could cost an individual over $17,000 annually. Typical health insurance may only cover sixty percent of costs for counseling, medication, and hospitalization. A one month prescription for lithium may cost $40 or more and the average cost for one month of Seroquel is $500. A counseling session with a psychotherapist runs, on average, $100, and a four day visit to a mental hospital can cost at least $500, possibly more. These prices may not seem quite so steep to some, but keep in mind that bipolar disorder can create disabilities. People with out of control bipolar disorder are less likely to own homes, have jobs that will easily support them through their lives, or be able to further their education to achieve higher job status. Bipolar mania creates racing thoughts, which makes it hard for an individual to focus and do well in schooling or employment. It can also make the individual compulsive in spending and relationships with coworkers and employers. Bipolar depression can lead to an individual avoiding normal activities, such as, work, school, and training. All these things can contribute to a deficiency in funds, which can instill a need for social workers in order to apply for help through Medicaid or Medicare. Also, a social worker can help an individual with bipolar disorder find proper counseling, set up crisis plans, and determine what kind of treatment is needed.
          Professional social workers may achieve their doctorate in social work to do research or social work education. This entire journal could not have been written at all without someone to research it. This study involved many different ways of treating bipolar disorder, such as, medication, psychotherapy, and hospitalization. It demonstrates that bipolar disorder cannot be looked at in just one view, but there is enormous diversity in this one disorder. Without this knowledge, stereotyping mental illness patients could be a serious problem.
         This study shows how the ecological system is affected by bipolar disorder. The patient may get more out of psychotherapy by involving a family member within the microsystem. This involves the mesosystem. Since bipolar disorder can create disabilities that prevent an individual from holding a job or completing education, the exosystem is involved. Finally, this research shows how individual patients can affect the macrosystem by participating in studies.
         This journal shows us many ways of how social work is affected by bipolar disorder and mental illness in general. It is particularly relevant to what we are studying now because people with bipolar disorder make up a significant part of the population and also affects a large part of the surrounding population.