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.

ADHERENCE MAY BE DEFINED AS the extent to which a patient’s behavior (in terms of taking medication, following a diet, modifying habits, or attending clinics) coincides with medical or health advice. If a patient is prescribed an antibiotic for an infection to be taken as 1 tablet 4 times a day for a week but takes only 2 tablets a day for 5 days, the adherence would be 36% (10/28). The term adherence is intended to be nonjudgmental, a statement of fact rather than of blame of the prescriber, patient, or treatment. Compliance and concordance are synonyms for adherence. This simple definition of adherence belies the difficulties that many medical regimens present for patients. For example, the regimen described for type 2 diabetes mellitus in a previous article includes a special diet, increased exercise, smoking cessation, oral hypoglycemic drugs, and risk factor management, usually involving additional drugs. Such regimens fulfill theoretical, physiological, and empirical considerations about optimal care, while ignoring practical patient-centered concerns, such as the nature, nurture, culture, and stereotyping of the patient, and the inconvenience, cost, and adverse effects of the treatment. Indeed, low adherence with prescribed treatments is very common. Typical adherence rates for prescribed medications are about 50% with a range of 0% to more than 100%.

Interventions to Enhance Patient Adherence to Medication Prescriptions

ContextLow adherence with prescribed treatments is ubiquitous and undermines
treatment benefits.ObjectiveTo systematically review published randomized controlled trials (RCTs)
of interventions to assist patients' adherence to prescribed medications.Data SourcesA search of MEDLINE, CINAHL, PSYCHLIT, SOCIOFILE, IPA, EMBASE, The Cochrane
Library databases, and bibliographies was performed for records from 1967
through August 2001 to identify relevant articles of all RCTs of interventions
intended to improve adherence to self-administered medications.Study Selection and Data ExtractionStudies were included if they reported an unconfounded RCT of an intervention
to improve adherence with prescribed medications for a medical or psychiatric
disorder; both adherence and treatment outcome were measured; follow-up of
at least 80% of each study group was reported; and the duration of follow-up
for studies with positive initial findings was at least 6 months. Information
on study design features, interventions, controls, and findings (adherence
rates and patient outcomes) were extracted for each article.Data SynthesisStudies were too disparate to warrant meta-analysis. Forty-nine percent
of the interventions tested (19 of 39 in 33 studies) were associated with
statistically significant increases in medication adherence and only 17 reported
statistically significant improvements in treatment outcomes. Almost all the
interventions that were effective for long-term care were complex, including
combinations of more convenient care, information, counseling, reminders,
self-monitoring, reinforcement, family therapy, and other forms of additional
supervision or attention. Even the most effective interventions had modest
effects.ConclusionsCurrent methods of improving medication adherence for chronic health
problems are mostly complex, labor-intensive, and not predictably effective.
The full benefits of medications cannot be realized at currently achievable
levels of adherence; therefore, more studies of innovative approaches to assist
patients to follow prescriptions for medications are needed.

https://jamanetwork.com/journals/jama/articlepdf/195605/JSR20016.pdf

Interventions to enhance patient adherence to medication prescriptions: scientific review.

Background. While there is a growing body of evidence on the efficacy of psychological interventions for schizophrenia, this meta-analysis improves upon previous systematic and meta-analytical reviews by including a wider range of randomized controlled trials and providing comparisons against both standard care and other active interventions. 

Method. Literature searches identified randomized controlled trials of four types of psychological interventions: family intervention, cognitive behavioural therapy (CBT), social skills training and cognitive remediation. These were then subjected to meta-analysis on a variety of outcome measures. This paper presents results relating to the first two.

Results. Family therapy, in particular single family therapy, had clear preventative effects on the outcomes of psychotic relapse and readmission, in addition to benefits in medication compliance. CBT produced higher rates of 'important improvement' in mental state and demonstrated positive effects on continuous measures of mental state at follow-up. CBT also seems to be associated with low drop-out rates.

Conclusions. Family intervention should be offered to people with schizophrenia who are in contact with carers. CBT may be useful for those with treatment resistant symptoms. Both treatments, in particular CBT, should be further investigated in large trials across a variety of patients, in various settings. The factors mediating treatment success in these interventions should be researched.

/pdf/psychological-treatments-in-schizophrenia-i-meta-analysis-of-4uma3ynsqp.pdf

Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy

Low adherence to prescribed medical regimens is a ubiquitous problem.
Typical adherence rates are about 50% for medications and are much lower for
lifestyle prescriptions and other more behaviorally demanding regimens. In
addition, many patients with medical problems do not seek care or drop out
of care prematurely. Although accurate measures of low adherence are lacking
for many regimens, simple measures, such as directly asking patients and watching
for appointment nonattendance and treatment nonresponse, will detect most
problems. For short-term regimens (≤2 weeks), adherence to medications
is readily achieved by giving clear instructions. On the other hand, improving
adherence to long-term regimens requires combinations of information about
the regimen, counseling about the importance of adherence and how to organize
medication taking, reminders about appointments and adherence, rewards and
recognition for the patient's efforts to follow the regimen, and enlisting
social support from family and friends. Successful interventions for long-term
regimens are all labor-intensive but ultimately can be cost-effective.

https://jamanetwork.com/journals/jama/articlepdf/195606/JSR20017.pdf

Helping Patients Follow Prescribed Treatment: Clinical Applications

BACKGROUND We developed and evaluated a comprehensive, ongoing intervention for families of schizophrenic patients appropriate for China's complex family relationships and unique social environment.

METHOD Sixty-three DSM-III-R schizophrenic patients living with family members were enrolled when admitted to hospital and randomly assigned to receive standard care or a family-based intervention that included monthly 45-minute counselling sessions focused on the management of social and occupational problems, medication management, family education, family group meetings, and crisis intervention.

RESULTS At 6, 12, and 18-month follow-ups by blind evaluators, the proportion of subjects rehospitalised was lower, the duration of rehospitalisation was shorter, and the duration of employment was longer in the experimental group than in the control group; these differences were statistically significant at the 12 and 18-month follow-ups and were not explained by differences in drug compliance. Family intervention was associated with significantly lower levels of family burden.

CONCLUSIONS This intervention is less costly than standard treatment, is suitable for urban families of schizophrenic patients in China and feasible given the constraints of the Chinese mental health system.

Ruiwen Wang

Papers

Family-based intervention for schizophrenic patients in China. A randomised controlled trial.