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

WRITING GROUP MEMBERS Emelia J. Benjamin, MD, SCM, FAHA Michael J. Blaha, MD, MPH Stephanie E. Chiuve, ScD Mary Cushman, MD, MSc, FAHA Sandeep R. Das, MD, MPH, FAHA Rajat Deo, MD, MTR Sarah D. de Ferranti, MD, MPH James Floyd, MD, MS Myriam Fornage, PhD, FAHA Cathleen Gillespie, MS Carmen R. Isasi, MD, PhD, FAHA Monik C. Jiménez, ScD, SM Lori Chaffin Jordan, MD, PhD Suzanne E. Judd, PhD Daniel Lackland, DrPH, FAHA Judith H. Lichtman, PhD, MPH, FAHA Lynda Lisabeth, PhD, MPH, FAHA Simin Liu, MD, ScD, FAHA Chris T. Longenecker, MD Rachel H. Mackey, PhD, MPH, FAHA Kunihiro Matsushita, MD, PhD, FAHA Dariush Mozaffarian, MD, DrPH, FAHA Michael E. Mussolino, PhD, FAHA Khurram Nasir, MD, MPH, FAHA Robert W. Neumar, MD, PhD, FAHA Latha Palaniappan, MD, MS, FAHA Dilip K. Pandey, MBBS, MS, PhD, FAHA Ravi R. Thiagarajan, MD, MPH Mathew J. Reeves, PhD Matthew Ritchey, PT, DPT, OCS, MPH Carlos J. Rodriguez, MD, MPH, FAHA Gregory A. Roth, MD, MPH Wayne D. Rosamond, PhD, FAHA Comilla Sasson, MD, PhD, FAHA Amytis Towfighi, MD Connie W. Tsao, MD, MPH Melanie B. Turner, MPH Salim S. Virani, MD, PhD, FAHA Jenifer H. Voeks, PhD Joshua Z. Willey, MD, MS John T. Wilkins, MD Jason HY. Wu, MSc, PhD, FAHA Heather M. Alger, PhD Sally S. Wong, PhD, RD, CDN, FAHA Paul Muntner, PhD, MHSc On behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Heart Disease and Stroke Statistics—2017 Update

Heart Disease and Stroke Statistics—2017 Update: A Report From the American Heart Association

Schizophrenia is a highly heritable disorder. Genetic risk is conferred by a large number of alleles, including common alleles of small effect that might be detected by genome-wide association studies. Here we report a multi-stage schizophrenia genome-wide association study of up to 36,989 cases and 113,075 controls. We identify 128 independent associations spanning 108 conservatively defined loci that meet genome-wide significance, 83 of which have not been previously reported. Associations were enriched among genes expressed in brain, providing biological plausibility for the findings. Many findings have the potential to provide entirely new insights into aetiology, but associations at DRD2 and several genes involved in glutamatergic neurotransmission highlight molecules of known and potential therapeutic relevance to schizophrenia, and are consistent with leading pathophysiological hypotheses. Independent of genes expressed in brain, associations were enriched among genes expressed in tissues that have important roles in immunity, providing support for the speculated link between the immune system and schizophrenia.

/pdf/biological-insights-from-108-schizophrenia-associated-3rfvth8dm9.pdf

Biological insights from 108 schizophrenia-associated genetic loci

Author(s): Writing Group Members; Mozaffarian, Dariush; Benjamin, Emelia J; Go, Alan S; Arnett, Donna K; Blaha, Michael J; Cushman, Mary; Das, Sandeep R; de Ferranti, Sarah; Despres, Jean-Pierre; Fullerton, Heather J; Howard, Virginia J; Huffman, Mark D; Isasi, Carmen R; Jimenez, Monik C; Judd, Suzanne E; Kissela, Brett M; Lichtman, Judith H; Lisabeth, Lynda D; Liu, Simin; Mackey, Rachel H; Magid, David J; McGuire, Darren K; Mohler, Emile R; Moy, Claudia S; Muntner, Paul; Mussolino, Michael E; Nasir, Khurram; Neumar, Robert W; Nichol, Graham; Palaniappan, Latha; Pandey, Dilip K; Reeves, Mathew J; Rodriguez, Carlos J; Rosamond, Wayne; Sorlie, Paul D; Stein, Joel; Towfighi, Amytis; Turan, Tanya N; Virani, Salim S; Woo, Daniel; Yeh, Robert W; Turner, Melanie B; American Heart Association Statistics Committee; Stroke Statistics Subcommittee

Heart Disease and Stroke Statistics—2016 Update: A Report From the American Heart Association

March 5, 2019 e1 WRITING GROUP MEMBERS Emelia J. Benjamin, MD, ScM, FAHA, Chair Paul Muntner, PhD, MHS, FAHA, Vice Chair Alvaro Alonso, MD, PhD, FAHA Marcio S. Bittencourt, MD, PhD, MPH Clifton W. Callaway, MD, FAHA April P. Carson, PhD, MSPH, FAHA Alanna M. Chamberlain, PhD Alexander R. Chang, MD, MS Susan Cheng, MD, MMSc, MPH, FAHA Sandeep R. Das, MD, MPH, MBA, FAHA Francesca N. Delling, MD, MPH Luc Djousse, MD, ScD, MPH Mitchell S.V. Elkind, MD, MS, FAHA Jane F. Ferguson, PhD, FAHA Myriam Fornage, PhD, FAHA Lori Chaffin Jordan, MD, PhD, FAHA Sadiya S. Khan, MD, MSc Brett M. Kissela, MD, MS Kristen L. Knutson, PhD Tak W. Kwan, MD, FAHA Daniel T. Lackland, DrPH, FAHA Tené T. Lewis, PhD Judith H. Lichtman, PhD, MPH, FAHA Chris T. Longenecker, MD Matthew Shane Loop, PhD Pamela L. Lutsey, PhD, MPH, FAHA Seth S. Martin, MD, MHS, FAHA Kunihiro Matsushita, MD, PhD, FAHA Andrew E. Moran, MD, MPH, FAHA Michael E. Mussolino, PhD, FAHA Martin O’Flaherty, MD, MSc, PhD Ambarish Pandey, MD, MSCS Amanda M. Perak, MD, MS Wayne D. Rosamond, PhD, MS, FAHA Gregory A. Roth, MD, MPH, FAHA Uchechukwu K.A. Sampson, MD, MBA, MPH, FAHA Gary M. Satou, MD, FAHA Emily B. Schroeder, MD, PhD, FAHA Svati H. Shah, MD, MHS, FAHA Nicole L. Spartano, PhD Andrew Stokes, PhD David L. Tirschwell, MD, MS, MSc, FAHA Connie W. Tsao, MD, MPH, Vice Chair Elect Mintu P. Turakhia, MD, MAS, FAHA Lisa B. VanWagner, MD, MSc, FAST John T. Wilkins, MD, MS, FAHA Sally S. Wong, PhD, RD, CDN, FAHA Salim S. Virani, MD, PhD, FAHA, Chair Elect On behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee

Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association

To the Editor: Dialogue on the design, conduct, analysis, and reporting of comparative effectiveness research is important for formulating valid treatment guidance and ensuring effective and efficient health care resource utilization. The analysis by Barnett et al1 assessed the cost-effectiveness of long-acting injectable (LAI) risperidone versus physician’s choice of oral antipsychotics in Veterans Health Administration patients with unstable schizophrenia or schizoaffective disorder. The study on which this analysis was based (Rosenheck et al2) was partly funded by our company. We fully support research characterizing our products’ efficacy, safety, appropriate use, and cost-effectiveness. However, aspects of this analysis and its interpretation warrant discussion. The original study was designed to evaluate whether LAI risperidone was superior to oral alternatives. The nonsignificant test for superiority cannot support Barnett and colleagues’ conclusion of no between-group difference in outcomes (ie, “adoption of long-acting risperidone would increase pharmaceutical costs without any improvement in outcomes”1[p701]). Such a conclusion requires a different study design and a larger sample. The conclusion that LAI risperidone is not cost-effective was based on higher medication costs versus oral agents; however, total between-group health care costs per quarter were not significantly different ($14,916 vs $13,980, respectively; P = .732). This lack of difference is despite the fact that higher proportions of the LAI risperidone group versus the oral antipsychotics group were hospitalized at randomization (45.5% vs 35.2%, P < .01) and had “problems with alcohol or drug use” (40.6% vs 33.5%; reported by Rosenheck et al2). Subjects in the LAI risperidone group also had a longer index hospitalization (mean = 1.0 vs 0.3 days, P = .021). Thus, LAI risperidone–treated subjects were more recently ill, were less stable, and had more comorbidity and therefore differed in risk for treatment nonadherence and rehospitalization. Further, the baseline hospitalization imbalance between groups resulted in cost differences that inflated costs in the LAI risperidone group and therefore limit interpretation of results. The original study2 reported that 45% (81/182) of patients in the oral treatment group and 39% (72/187) of patients in the LAI risperidone group were hospitalized. Some oral agent subjects switched to LAI risperidone during the trial (discrepant numbers: 21 of 182 [12%] in Rosenheck et al2; 41 of 182 [22.5%] in Barnett et al1). Despite this, the odds ratio for hospitalization was 28% greater for oral treatment (OR = 1.28; 95% CI, 0.85–1.94). If switching from oral agents prevented hospitalizations (treatment failure) in ≤ 21 patients, the risk increases up to 103% greater for oral agents (if ≤ 41 hospitalizations were prevented, the risk is up to 224% greater). Research evaluating comparative efficacy in narrowly defined subpopulations must be cautiously translated to broader populations. This is particularly true of LAIs, for which the key differentiator relates to adherence rather than pharmacology. The protocol-specified enhanced visit frequency and intensity of this trial may have eliminated or significantly attenuated the naturalistic environment necessary to demonstrate compliance advantages of biweekly LAI risperidone dosing by health care professionals. In summary, results from this study, powered for superiority, do not support the conclusion that LAI risperidone is “not cost-effective” compared to oral agents. The possibility that in a naturalistic setting LAI risperidone would be cost-effective cannot be excluded given differences in treatment groups and the explanatory characteristics of this study design. RefeRences

Drs Barnett and Rosenheck Reply

Does stimulant use impair housing outcomes in low-demand supportive housing for chronically homeless adults?: Stimulant Use and Housing Outcomes

Reduction of suicidality among psychiatric patients over the course of a hospital stay.

Background: Suicide prevention is a major public health priority. The effectiveness of suicide prevention initiatives is typically assessed by reductions in incidents of suicidal behavior. However, the association of suicide attempts with changes in measures of overall health-related quality of life (HRQOL) has been understudied.
Methods: Nationally representative data from 36,309 adults from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III) were used to compare 3 groups: individuals with any suicide attempt in the past 3 years, individuals with a suicide attempt prior to the past 3 years, and those with no prior attempts. Using the 12-item Short Form (SF-12) items, standard measures of mental component score (MCS) and physical component score (PCS) of HRQOL and of quality-adjusted life-years (QALYs) were constructed and compared across these groups. Multivariable regression analyses adjusted scores for sociodemographic, diagnostic, and behavioral covariates.
Results: Overall, 1.0% (n = 355) reported an attempt in the last 3 years, 4.3% (n = 1,569) reported an attempt prior to the past 3 years, and 94.7% (n = 34,385) had no prior attempt. In unadjusted analysis, individuals with recent attempts reported much lower MCS scores compared to individuals with no prior attempts (-13.5 points; 95% confidence interval [CI], -15.4 to -11.6) as well as those with past attempts (-7.7 points; 95% CI, -8.5 to -7.0). QALYs were also much lower (-0.13; 95% CI, -0.14 to -0.11 for those with recent attempts and -0.09; 95% CI, -0.10 to -0.08 for those with past attempts, respectively). Adjustment for correlated factors, especially psychiatric disorders and substance use disorders, accounted for 75%-86% of the association of recent and past suicide attempts with MCS-HRQOL and 89%-91% of QALYs; ie, these factors were largely incorporated in these measures of HRQOL.
Conclusions: Individuals with relatively recent suicide attempts report significantly lower MCS-HRQOL and QALYs compared to both individuals with no prior attempts and individuals with more remote attempts. Psychiatric and substance use comorbidities account for most but not all of the group differences in these measures and thus provide a brief approach to assessing suicide prevention initiatives encompassing multiple aspects of well-being and providing a basis for future cost-benefit analysis.

Association of Recent and Past Suicide Attempts With Health-Related Quality of Life.

Objective: Community-based intensive case management may be more intense than necessary and may be socially isolating for persons living in supported housing. This study evaluated a group intensive peer-support (GIPS) model of case management that was implemented in a supportedhousing program for homeless veterans with a broad range of psychiatric, substance use, and general medical problems. Group meetings led by case managers are the default mode of case management support, and individual intensive case management is provided only when clinically necessary. Methods: GIPS was implemented by the U.S. Department of Housing and Urban Development–Veterans Affairs Supportive Housing (HUD-VASH) program at one demonstration site in April 2010. The study used administrative data to compare outcomes, service delivery, and timing of housing acquisition among clients of the demonstration site one year before (N=102) and after (N=167) GIPS implementation and among clients of other HUD-VASH sites across the country before (N=9,659) and after (N=21,318) implementation of GIPS at the demonstration site. Results: After adjustment for differences in baseline characteristics, the analyses found that GIPS implementation was associated with a greater increase in social integration ratings, a greater number of case manager services, and faster acquisition of Section 8 housing vouchers after program admission compared with outcomes at the same site before GIPS implementation and at the other sites before and after implementation. Conclusions: GIPS may be a viable service model of supported housing that represents a recovery-oriented approach that can be scaled up to address homelessness. (Psychiatric Services 63:1186–1194, 2012; doi:

https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201200100

Robert A. Rosenheck

Papers

Drs Barnett and Rosenheck Reply

Does stimulant use impair housing outcomes in low-demand supportive housing for chronically homeless adults?: Stimulant Use and Housing Outcomes

Reduction of suicidality among psychiatric patients over the course of a hospital stay.

Association of Recent and Past Suicide Attempts With Health-Related Quality of Life.

OutcomesofaGroupIntensive Peer-SupportModelofCase ManagementforSupportedHousing