Effect of Adherence Therapy in Young People with Psychosis

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  • Structured medication problem solving: tackling practical problems with medications, e.g. side effects or remembering to take pillsLooking back: using timelines to help patient review past experiences of illness and medication – reflect on effects of medication. Therefore learning from past to apply to future.Exploring ambivalence: Help patient to consider the “good and not so good” aspects of taking and not taking medication therefore exploring natural ambivalence towards taking antipsychotic medicationTalking about beliefs and concerns: Testing out commonly held beliefs about medication using conviction scales and evidence for and against each belief.Looking forward: Helping patients to consider ‘life goals’ and the role medication may play in achieving these.
  • Effect of Adherence Therapy in Young People with Psychosis

    1. 1. Effectiveness of adherence therapy in young people with psychosis<br />Dr Martin Jones Associate Director of Nursing<br />Simon Whitfield Chief Pharmacist<br />
    2. 2. Overview<br />
    3. 3. Stopping medication is the most powerful predictor of relapse<br />6<br />4.89<br />4.57<br />5<br />4<br />Hazard ratio<br />3<br />2<br />1<br />n=104<br />n=63<br />0<br /> Second relapse<br />First relapse <br />Survival analysis of relapse using medication status as a time-dependent covariate risk <br />The risk of a first or second relapse when not taking medication is ~5 times greater than when taking it<br />Robinson et al. Arch Gen Psychiatry 1999;56:241–247<br />
    4. 4.
    5. 5. Mean number of days <br />with ‘no therapy’<br />Continuous therapy <br />ANY ‘no therapy’ days<br />†<br />5.2%<br />7.1%<br />100<br />350<br />94.8%<br />92.9%<br />300<br />80<br />250<br />60<br />Patients (%)<br />200<br />Days<br />125.0<br />40<br />150<br />110.2<br />100<br />20<br />n=349<br />n=326<br />n=349<br />n=326<br />50<br />0<br />0<br />SGA<br />FGA<br />FGA<br />SGA<br />Adherence affects almost all patients*<br />High percentages of patients receiving oral SGA and FGA treatment received no antipsychotic therapy for a substantial portion of study follow-up<br />*Based on availability of medication in a 1-year naturalistic study; †’No therapy’ defined as days in which medication was not available. <br /> Patients were considered to be receiving therapy on days when medication was available and COULD have been taken<br />Mahmoud et al. Clin Drug Invest 2004;24:275–286<br />FGA, first-generation antipsychotic; SGA, second-generation antipsychotic<br />
    6. 6. To paraphrase: “An effective intervention to improve adherence is worthy of a Nobel Prize”<br />
    7. 7. What do patients think about antipsychotic medication?<br />
    8. 8. What do patients think about their medication?<br />26 patients <br />Early psychosis<br />Prescribed antipsychotic medication<br />Most striking observation<br />Patients had a mix of positive and negative views about antipsychotic medication<br />Discrepant with the “Noise”<br />Meek I. and Gray R. (in preparation)<br />
    9. 9. What do patients think about their medication?<br /><ul><li>Theme: There has to be something else
    10. 10. “It is the companies and the research; I was dead against them when I was first taking it because of how it made me feel. I started to accumulate reasons not to take it. I raged against the drug companies and their propaganda, making themselves the best option…” [P10, Male, 30]
    11. 11. Theme: The drugs don’t work
    12. 12. “They keep people on these drugs for too long. I am no better than when I was not on them…” [P10, Female, 23]
    13. 13. “I get no effects from it. It does nothing to me. I don’t have a mental problem” [P4, Male, 27]</li></ul>Meek I. and Gray R. (in preparation)<br />
    14. 14. What do patients think of their medication?<br /><ul><li>Ambivalence
    15. 15. “It doesn’t chill me out enough. It doesn’t quite relieve my symptoms” [P12, Male, 30]
    16. 16. “If doesn’t work as well as I hoped for. I still feel worried/paranoid and I still hear voices. I’m relying on something to help me get through, although feeling it was not necessary to take it” [P6, Male, 22]
    17. 17. “I wish my medication got rid of all my symptoms. My thoughts are less distressing but I still have them at times” [P20, Male, 27]</li></ul>Meek I. and Gray R. (in preparation)<br />
    18. 18. What do patients think of their medication?<br /><ul><li>Theme: It does what it says on the tin
    19. 19. “The effectiveness of and the speed of it working for me. It worked within two weeks, it continued to be effective. I would recommend it as an effective antipsychotic drug” [P17, male, 28]
    20. 20. “They are doing what they are supposed to do with some thoughts. They are doing what they are supposed to do. That is the main factor [P18, Male, 28]
    21. 21. “I’m not so jumpy. It has made things more manageable [P13, Female, 35]</li></ul>Meek I. and Gray R. (in preparation)<br />
    22. 22. What do patients think of their medication?<br /><ul><li>Theme: side effects
    23. 23. Some patients said that they experienced no side effects at all
    24. 24. “I have no bad reactions, no side effects” [P6, Male, 22]
    25. 25. “I haven’t experienced any side effects” [P16, Female, 27]
    26. 26. Sedation was the most frequently reported and most troubling side effect
    27. 27. “The first time after taking it I couldn’t get up for 12 hours. Now 2-4 hours after taking it I can ‘get up’, but I can’t get out of bed. It makes me dark under my eyes. It makes you feel weak for hours. I have somehow to get used to it” [Patient 1, Male, 23]
    28. 28. “If you move about a lot you don’t notice it. If you take down time the effects seem to snow ball and it gets on top of you. If you’re tired it makes you more tired. It’s like walking in water. You learn to fight the resistance” [Patient 2, Male, 30] </li></ul>Meek I. and Gray R. (in preparation)<br />
    29. 29. What do patients think of their medication?<br /><ul><li>Theme: side effects
    30. 30. Some patients said that they experienced no side effects at all
    31. 31. “I have no bad reactions, no side effects” [P6, Male, 22]
    32. 32. “I haven’t experienced any side effects” [P16, Female, 27]
    33. 33. Sedation was the most frequently reported and most troubling side effect
    34. 34. “The first time after taking it I couldn’t get up for 12 hours. Now 2-4 hours after taking it I can ‘get up’, but I can’t get out of bed. It makes me dark under my eyes. It makes you feel weak for hours. I have somehow to get used to it” [Patient 1, Male, 23]
    35. 35. “If you move about a lot you don’t notice it. If you take down time the effects seem to snow ball and it gets on top of you. If you’re tired it makes you more tired. It’s like walking in water. You learn to fight the resistance” [Patient 2, Male, 30] </li></ul>Meek I. and Gray R. (in preparation)<br />
    36. 36. Why don’t patients take their medication? <br />
    37. 37.
    38. 38. Improving treatment adherence<br />
    39. 39. Candidate interventions<br />Patient education<br />Financial incentives<br />Depot (long acting injections)<br />Adherence therapy<br />Problem solving<br />Ambivalence<br />Beliefs<br />
    40. 40. The knowledge fallacy…<br />
    41. 41.
    42. 42. What is adherence therapy?<br />Collaborative approach<br />Theory is that by giving people choice and allowing people to make meaningful decisions about their care and treatment means they will stick with their treatment for longer leading to healthier outcomes<br />
    43. 43. Adherence therapy: theory<br />
    44. 44. Adherence Therapy: key components<br />Structured medication problem solving<br />Looking back<br />Exploring ambivalence<br />Talking about beliefs and concerns<br />Looking forward<br />
    45. 45. Does adherence therapy work?<br />Number of short term studies<br />Small scale<br />Highly motivated work force<br />So what about the real world setting?<br />
    46. 46. What we wanted to know?<br />Is it acceptable to staff?<br />Is it acceptable to patients?<br />Does it make a difference?<br />
    47. 47. From therapy to practice<br />Study Design<br />EIP<br />Whole team<br />Agree assessment measures (RAG system)<br />Interviews<br />Deliver intervention<br />Psychopharmacology training<br />Adherence therapy training (5-10 days)<br />Looked at impact 12 months post training and compared with the 12 months prior to training<br />
    48. 48. How has AT training made a difference? (staff)<br /><ul><li>“AT is carried out informally”
    49. 49. “Staff structure their time better”
    50. 50. “Work is more collaborative now”
    51. 51. “I have a much better understanding of how medicines work”
    52. 52. “AT ideas are used regularly in practice”
    53. 53. “Time is a barrier”
    54. 54. “…the skills can be forgotten over time”</li></li></ul><li>How has AT made a difference ? (patient)<br />They’ve been very informative about how it would help me and the possible side effects<br />They’ve been very clear, they’ve explained the different options…. and side effects very clearly<br />I think they’re very good<br />They’ve been really helpful, yeah<br />
    55. 55. Adherence therapy training in early psychosis: effect on relapse rates<br />P<.05<br />Mean number of relapses in past 12 months<br />Jones M. Brown E. Gray R. (in prep)<br />Design: Mirror image study (n=32)<br />Endpoint: Relapse in previous 12 months<br />
    56. 56. To paraphrase: “An effective intervention to improve adherence is worthy of a Nobel Prize”<br />

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