Predictors of adherence and outcome in schizophrenia
Richard Drake,Senior Lecturer in Adult Psychiatry,
University of Manchester
What I’m Going to Tell You
• Non-adherence predicts poor outcome• Determinants of adherence and
concordance – Insight relates to degree of concordance
• Poor insight predicts poor outcomes– it may predict poor outcome better than
adherence
• Insight and adherence can be changed
Predictors of Outcome in Schizophrenia
• Demographic– Sex, age
• Historical– Premorbid adjustment– DUP, Course of illness– Symptoms
• Behavioural– EE, Substance Misuse – Adherence, Engagement
Predictors of Outcome in Schizophrenia
• Demographic– Sex, age
• Historical– Premorbid adjustment– DUP, Course of illness– Symptoms
• Behavioural– EE, Substance Misuse – Adherence, Engagement
Davis & Andrukaitis 1986 J Clin Psychopharmacol
16.2% 57.6%
Drug Placebo
Davis & Andrukaitis 1986 J Clin Psychopharmacol
Adherence and Chronic Illness
• Stopping APS suddenly: 46% relapse in 6/12 if stable56% in two years
• Stopping gradually: 50% over 2 years
Viguera et al 1997
0
10
20
30
40
50
60
70
80
90
100
Survival (%)
Robinson D et al, Arch Gen Psych, 1999
Gaebel W et al 2002 Sz Res
Gaebel W et al 2002 Sz Res
Wunderink L et al 2005, 2007
MESIFOS STUDY
Determinants of Poor Adherence
• Maybe – isolation, youth and being male– substance abuse – more side effects or their subjective
experience – more frequent doses– Better or worse cognitive function
• Or not, for most of the above
More recent studies
• Internal rather than external locus of control
• High EE family• Poor therapeutic alliance• Negative attitudes • Poor insight
Influence of Others
Belief in Prevention
Medication Affinity
Vauth R et al, 2004 Psychiatry Res
Influence of Others
Belief in Prevention
Medication Affinity
Meaningful Work
Neuro-cognition
Length of Illness
No symptoms
Age
Vauth R et al, 2004 Psychiatry Res
Insight and medication attitudes
Day, J., et al. 2005 Arch Gen Psych 62 717-24
Insight and medication attitudes
Day, J., et al. 2005 Arch Gen Psych 62 717-24
The Construct of Insight
• Insight said to have different dimensions– E.g. recognising sx, illness, its social
consequences, & need for Rx; attributing sx to illness; “hypothetical contradiction”
• Insight appears to have cultural, symptomatic and neuropsychological determinants
Insight and Outcome
• In chronic samples predicts relapse, readmission, symptoms, objective QoL, adherence, other outcomes– perhaps including violence (esp. in short
term or in forensic populations).– Perhaps not including engagement?
• Insight during the process of relapse predicts readmission.
• However, these samples select for poor IS
Why does RLS predict relapse?
• Re-Labelling Symptoms predicts relapse– Unlike accepting NFT, awareness of
illness
• Chance finding?• Related to identifying relapse?• Related to substance misuse, EE?• Related to adherence?
Recent FE naturalistic studies
• Poor adherence in FE– definitions vary but most involve
stopping >7/7 as a minimum– Many of these will stop altogether for
some time– 33% over any 6 months– 42-59% at some point over 1-5years
• All multivariate analyses of predictors of adherence have global insight as significant– Except Coldham et al, 2002
• IS predicts irregular or non-adherence• Disappears when adjust for PM function,
age, cannabis at 1y, family support
Recent FE naturalistic studies
HBM and Adherence in a Trial
• Perkins et al. 2006: FE trial of APS in 254• Small effect of objective SE predicted
non-adherence• Lack of benefit too• Negative attitudes to medication did not• Awareness of benefits of medication in
reducing sx. & NFT both predicted good adherence
IS and Adherence in a Trial
• McEvoy et al. 2006: FE trial of 251 OLZ v HPL
• ITAQ scale predicted time to non-adherence
• Type of medication did not
FE cohorts and trials
• Global IS predicts adherence even after attitudes to medication
• In detail, awareness of past and future symptom reduction predicts continued adherence
• Negativity about medication or perceived SE not predictive; possibly objective SE
• Other aspects of insight inconsistent
Insight may be improved
• Specific IS-focussed CBT may improve it (Turkington et al, 2002, 2006; Rathod et al 2005)
– This form of CBT protected against depression
• Focussed CBT may alter attitudes to illness and self (Gumley et al, 2005)
• General CBT for psychosis may not improve IS or suicidality (Tarrier et al, 2006)
Adherence may be improved
• Psychoeducation about medication almost never effective
• Multi-modal interventions appear more likely to be effective – certainly more fashionable
Insight and medication attitudes
Day, J., et al. 2005 Arch Gen Psych 62 717-24
Adherence may be improved
• Combine education about meds & disorder with:– Behavioural approaches (techniques and
skills, reminders, reinforcement)– Work on therapeutic relationship– Use other interpersonal relationships,
feelings of loyalty etc. (“affective approaches”)
• May be effective individually, in groups or via services (e.g. supported housing)
Summary
• Certain attitudes may be more predictive of future adherence and relapse than current behaviour– There maybe a very disadvantaged
subgroup– Sealing over may predict
disengagement
Summary• Insight is associated with suicidality
– If you then become depressed and hopeless because you’re ashamed and overwhelmed
– It doesn’t help if you abuse substances
• Insight leads to adherence and improvement, which prevents the above
• Specific CBT might improve IS without depression
• Multimodal interventions improve adherence
P D
SE
NFM
+ve correlation -ve correlation
Well
AIS
DSH
Hosp