Basics of qualitative research: Grounded theory procedures and techniques

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.

A rating scale for drug-induced akathisia has been derived that incorporates diagnostic criteria for pseudoakathisia, and mild, moderate, and severe akathisia. It comprises items for rating the observable, restless movements which characterise the condition, the subjective awareness of restlessness, and any distress associated with the akathisia. In addition, there is an item for rating global severity. A standard examination procedure is recommended. The inter-rater reliability for the scale items (Cohen's kappa) ranged from 0.738 to 0.955. Akathisia was found in eight of 42 schizophrenic in-patients, and nine had pseudoakathisia, where the typical sense of inner restlessness was not reported.

A rating scale for drug-induced akathisia

Background Motivational Interviewing is a well-known, scientifically tested method of counselling clients developed by Miller and Rollnick and viewed as a useful intervention strategy in the treatment of lifestyle problems and disease.

Aim To evaluate the effectiveness of motivational interviewing in different areas of disease and to identify factors shaping outcomes.

Design of study A systematic review and meta-analysis of randomised controlled trials using motivational interviewing as the intervention.

Method After selection criteria a systematic literature search in 16 databases produced 72 randomised controlled trials the first of which was published in 1991. A quality assessment was made with a validated scale. A meta-analysis was performed as a generic inverse variance meta-analysis.

Results Meta-analysis showed a significant effect (95% confidence interval) for motivational interviewing for combined effect estimates for body mass index, total blood cholesterol, systolic blood pressure, blood alcohol concentration and standard ethanol content, while combined effect estimates for cigarettes per day and for HbA1c were not significant. Motivational interviewing had a significant and clinically relevant effect in approximately three out of four studies, with an equal effect on physiological (72%) and psychological (75%) diseases. Psychologists and physicians obtained an effect in approximately 80% of the studies, while other healthcare providers obtained an effect in 46% of the studies. When using motivational interviewing in brief encounters of 15 minutes, 64% of the studies showed an effect. More than one encounter with the patient ensures the effectiveness of motivational interviewing.

Conclusion Motivational interviewing in a scientific setting outperforms traditional advice giving in the treatment of a broad range of behavioural problems and diseases. Large-scale studies are now needed to prove that motivational interviewing can be implemented into daily clinical work in primary and secondary health care.

Motivational interviewing: a systematic review and meta-analysis

/pdf/update-on-empirically-validated-therapies-ii-37totkzzc1.pdf

Update on Empirically Validated Therapies, II

BACKGROUND People with severe mental illness often have a complex mixture of clinical and social needs The Camberwell Assessment of Need (CAN) is a new instrument which has been designed to provide a comprehensive assessment of these needs There are two versions of the instrument: the clinical version has been designed to be used by staff to plan patients' care; whereas the research version is primarily a mental health service evaluation tool The CAN has been designed to assist local authorities to fulfil their statutory obligations under the National Health Service and Community Care Act 1990 to assess needs for community services

METHOD A draft version of the instrument was designed by the authors Modifications were made following comments from mental health experts and a patient survey Patients (n = 49) and staff (n = 60) were then interviewed, using the amended version, to assess the inter-rater and test-retest reliability of the instrument

RESULTS The mean number of needs identified per patient ranged from 755 to 864 Correlations of the inter-rater and test-retest reliability of the total number of needs identified by staff were 099 and 078 respectively The percentage of complete agreement on individual items ranged from 100-816% (inter-rater) and 100-581% (test-retest)

CONCLUSIONS The study suggests that the CAN is a valid and reliable instrument for assessing the needs of people with severe mental illness It is easily learnt by staff from a range of professional backgrounds, and a complete assessment took, on average, around 25 minutes

The Camberwell Assessment of Need: the validity and reliability of an instrument to assess the needs of people with severe mental illness.

Objective: To determine whether compliance therapy, a cognitive-behavioural intervention, could improve compliance with treatment and hence social adjustment in acutely psychotic inpatients, and if so, whether the effect persisted six months later. Design: Randomised controlled trial of compliance therapy and non-specific counselling, each comprising 4-6 sessions lasting 10-60 minutes. Setting: Acute psychiatric admissions ward serving an inner London catchment area. Subjects: 47 patients with psychosis. Main outcome measures: Informant and observer reported measure of compliance; observer assessed global functioning after intervention and three and six months later; self rated attitudes to drug treatment after the intervention and one month later; symptom scores after intervention and six months later. Results: 25 patients received compliance therapy and showed significantly greater improvements in their attitudes to drug treatment and in their insight into illness and compliance with treatment compared with the control group. These gains persisted for six months. The intervention group was 5.2 times more likely than the control group to reach a criterion level of compliance (95% confidence interval 1.5 to 18.3). Global functioning showed a tendency to improve more in the intervention group after a delay (odds ratio 3.0 (0.8 to 11.5) to reach the criterion level at six months). Four subjects given compliance therapy and six in the control group were readmitted during follow up (odds ratio 2.0 (0.48 to 8.2)). Conclusions: Compliance therapy is a pragmatic method for improving compliance with drug treatment in psychotic inpatients and its gains persist for at least six months. Overall functioning may also be enhanced. Key messages Key messages Compliance is strongly related to attitudes to treatment and to insight The study found that such attitudes may be influenced by a simple and brief intervention known as compliance therapy Compliance therapy compared with non-specific counselling leads to improved compliance The improvement is sustained for at least six months and may lead to improved social functioning

Compliance therapy in psychotic patients: randomised controlled trial

BACKGROUND: 
A randomised controlled trial was conducted in an acute treatment setting to examine the effectiveness of compliance therapy, a brief pragmatic intervention targeting treatment adherence in psychotic disorders, based on motivational interviewing and recent cognitive approaches to psychosis.

METHOD: 
Seventy-four patients with psychotic disorders according to DSM-III-R criteria recruited from consecutive admissions to an acute in-patient unit, received 4-6 sessions of either compliance therapy or non-specific counselling, and were followed-up over 18 months. The principal outcome measures were observer-rated compliance, attitudes to treatment, insight and social functioning.

RESULTS: 
Significant advantages were found for the compliance therapy group post-treatment on measures of insight, attitudes to treatment and observer-rated compliance which were retained over the follow-up period. Global social functioning improved relatively more over time in the compliance therapy group compared with the control group. Survival in the community prior to readmission was significantly longer in the compliance therapy group.

CONCLUSIONS: 
The results support the effectiveness of compliance therapy in improving functioning and community tenure after an acute psychotic episode.

Randomised controlled trial of compliance therapy. 18-month follow-up.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(04)17224-3.pdf

Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study

Background: Recent investigations provide evidence of stigma against people with a diagnosis of mental illness. Aims: The purpose of this study was to provide an account of the life experiences of persons with schizophrenia. Focusing on the individuals’ personal reports of events and situations, the issues of stigmatisation and discrimination were explored. Method: Six participants were interviewed using a semi-structured schedule focusing on the areas of personal history, understanding of schizophrenia, social and medical contextualisation, and reflection on impact. The research was conducted using Interpretative Phenomenological Analysis (IPA) (Smith, 1996, 1999). Results: Super-ordinate themes of judgement, comparison, and personal understanding of the (mental health) issue emerged. Stigma was evident both as public-stigma and as self-stigma. Conclusions: The ramifications of stigma and discrimination are enduring and potentially disabling. IPA is a constructive tool in exploring these issues.

/pdf/people-don-t-understand-an-investigation-of-stigma-in-4qgggg7ff2.pdf

Peter Hayward

Papers

The Camberwell Assessment of Need: the validity and reliability of an instrument to assess the needs of people with severe mental illness.

Compliance therapy in psychotic patients: randomised controlled trial

Randomised controlled trial of compliance therapy. 18-month follow-up.

Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study

'People don't understand': An investigation of stigma in schizophrenia using Interpretative Phenomenological Analysis (IPA)