The full benefit of many effective medications will be achieved only if patients adhere to prescribed treatment regimens. Unfortunately, applying terms such as “noncompliant” and “nonadherent” to patients who do not consume every pill at the desired time can stigmatize them in their future relationships with health care providers. This article on medication adherence (or compliance) reviews strategies to assess and enhance this important aspect of patient care.

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Adherence to Medication

Almost since the beginnings of psychiatric practice, there has been a recognition that negative life experiences and stressful happenings may serve to precipitate mental disorders (Garmezy & Rutter, 1985). Nearly 200 years ago, Pinel wrote about the psychiatric risks associated with unexpected reverses or adverse circumstances, and it is reported that his initial question to newly admitted psychiatric patients was: “Have you suffered vexation, grief or reverse of fortune?” Nevertheless, although an appreciation that a variety of stressors may play a role in the genesis of psychiatric disorder has a long history, the systematic study of such effects is much more recent.

Resilience in the face of adversity. Protective factors and resistance to psychiatric disorder.

Background: Special care facilities for patients with dementia gain increasing attention. However, an overview of studies examining the differences between care f

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Special Care Units and Traditional Care in Dementia: Relationship with Behavior, Cognition, Functional Status and Quality of Life - A Review

Background
People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

Objectives
To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

Search methods
We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

Selection criteria
Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

Data collection and analysis
Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

Main results
For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 83 interventions reported in 70 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

Authors' conclusions
For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Interventions for enhancing medication adherence.

This article reviews the various literatures on the adjustment of children of depressed parents, difficulties in parenting and parent-child interaction in these families, and contextual factors that may play a role in child adjustment and parent depression. First, issues arising from the recurrent, episodic, heterogeneous nature of depression are discussed. Second, studies on the adjustment of children with a depressed parent are summarized. Early studies that used depressed parents as controls for schizophrenic parents found equivalent risk for child disturbance. Subsequent studies using better-defined samples of depressed parents found that these children were at risk for a full range of adjustment problems and at specific risk for clinical depression. Third, the parenting difficulties of depressed parents are described and explanatory models of child adjustment problems are outlined. Contextual factors, particularly marital distress, remain viable alternative explanations for both child and parenting problems. Fourth, important gaps in the literature are identified, and a consistent, if unintentional, "mother-bashing" quality in the existing literature is noted. Given the limitations in knowledge, large-scale, long-term, longitudinal studies would be premature at this time.

Children of depressed parents: an integrative review.

This study is a replication and extension of past work carried out by Brown, Birley and Wing (1972) concerning the influence of family life on the course of schizophrenia. In the original research the index of emotion expressed by a key relative about the patient at the time of key admission proved to be the best single predictor of symptomatic relapse in the nine months after discharge from hospital. In the present study this main finding of Brown et al has been replicated for two clinically different groups of psychiatric patients. The expressed emotion of the relative again seems to be associated with relapse independently of all other social and clinical factors investigated. In addition, important additive effects between various social influences and pharmacological treatments have been revealed which make it possible to predict relapse patterns in schizophrenia with considerable precision. The patterns of these relationships with relapse are different for the two clinical groups studied, patients with schizophrenic psychosis and with depressive neurosis.

The influence of family and social factors on the course of psychiatric illness. A comparison of schizophrenic and depressed neurotic patients.

In a series of studies of the influence of family life on the course of an established schizophrenic illness, it has been shown that the level of emotion expressed by relatives shortly after a schizophrenic patient is admitted to hospital is strongly associated with symptomatic relapse during the nine months following discharge (Brown et al., 1962, 1972). This paper states the case for an abbreviated version of the primary research instrument used in these studies, the Camberwell Family Interview Schedule. In the 1972 study the single most important measure contributing to the overall expressed emotion index proved to be the number of critical remarks made about the patient by the relative when interviewed alone. An analysis of 15 tape-recorded interviews from this study showed that the majority of critical comments were produced within the first hour and there was virtually no relationship between total number of critical comments and length of interview (r = 0.08). This analysis supported the use of a shortened interview in which the areas most likely to produce any criticism were given priority in the sequence of questioning. This abbreviated version has been used successfully in a replication and extension of the 1972 study. A group of 37 schizophrenic patients is being compared with a group of 31 depressed neurotic patients. Patterns of emotional response of these patients' relatives are discussed.

The Measurement of Expressed Emotion in the Families of Psychiatric Patients

A study is reported of a controlled trial of social intervention in the families of schizophrenic patients at high risk of relapse. The patients were selected for being in high contact with high Expressed Emotion relatives. All patients were maintained on neuroleptic drugs. One half of the 24 families were randomly assigned to routine out-patient care, while the other half received a package of social interventions. This comprised a programme of education about schizophrenia, a group for the relatives, and family sessions for relatives and patients. The relapse rate in the control group was 50 per cent compared with nine per cent in the experimental group (P = 0.04). The stated aims of the therapeutic interventions were achieved in 73 per cent of experimental families. In these families, no patient relapsed. The results provide evidence for the causal role of relatives' expressed emotion (EE) in schizophrenic relapse, as well as for the therapeutic effectiveness of social intervention combined with drug treatment.

A controlled trial of social intervention in the families of schizophrenic patients.

Expressed emotion in families

Background The incidence of schizophrenia in the African-Caribbean population in England is reported to be raised We sought to clarify whether (a) the rates of other psychotic disorders are increased, (b) whether psychosis is increased in other ethnic minority groups, and (c) whether particular age or gender groups are especially at risk Method We identified all people (n=568) aged 16-64 years presenting to secondary services with their first psychotic symptoms in three well-defined English areas (over a 2-year period in Southeast London and Nottingham and a 9-month period in Bristol) Standardized incidence rates and incidence rate ratios (IRR) for all major psychosis syndromes for all main ethnic groups were calculated Results We found remarkably high IRRs for both schizophrenia and manic psychosis in both African-Caribbeans (schizophrenia 9  1, manic psychosis 8  0) and Black Africans (schizophrenia 5  8, manic psychosis 6  2) in men and women IRRs in other ethnic minority groups were modestly increased as were rates for depressive psychosis and other psychoses in all minority groups These raised rates were evident in all age groups in our study Conclusions Ethnic minority groups are at increased risk for all psychotic illnesses but African- Caribbeans and Black Africans appear to be at especially high risk for both schizophrenia and mania These findings suggest that (a) either additional risk factors are operating in African- Caribbeans and Black Africans or that these factors are particularly prevalent in these groups, and that (b) such factors increase risk for schizophrenia and mania in these groups

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Julian Leff

Papers

The influence of family and social factors on the course of psychiatric illness. A comparison of schizophrenic and depressed neurotic patients.

The Measurement of Expressed Emotion in the Families of Psychiatric Patients

A controlled trial of social intervention in the families of schizophrenic patients.

Expressed emotion in families

Incidence of schizophrenia and other psychoses in ethnic minority groups: results from the MRC AESOP study