Measuring adherence to antipsychotic medications for schizophrenia: Concordance and validity among a community sample in rural China

Xu, Dong; Gong, Weiping; Gloyd, Steve; Caine, Eric D.; Simoni, Jane M.; Xiao, Shuiyuan; He, Wenjun; Dai, Bofeng; Lin, Mu; Nie, Juan; He, Hua

doi:10.1016/j.schres.2018.05.014

Cited by 19 publications

(16 citation statements)

References 70 publications

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“…The self-reported adherence (Fig. 1) was similar to that obtained through the home-based pill count in 2016 (Xu et al, 2018). The rate of hospitalization in 2012 in Liuyang was 13%, which compared favorably to many other "686" localities (Bai et al, 2011;Wen et al, 2011).…”

Section: Discussionsupporting

confidence: 67%

“…We first performed descriptive analyses. Then we compared the functional levels of FMP enrollees between the refill-adherent and non-adherent groups, using propensity score analysis: we first calculate a "propensity score" for each participant; and then conduct a regression analysis to examine the relationship between functioning and refill-adherence, with those propensity scores included as covariates to control for known confounders (Xu et al, 2018). The propensity score is the probability of being assigned into an "exposure" conditional on observable covariates.…”

Section: Resultsmentioning

confidence: 99%

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The association between a free medicine program and functioning in people with schizophrenia: a cross-sectional study in Liuyang, China

Gong

Zhang

et al. 2020

PeerJ

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Background Persons with schizophrenia frequently discontinue or avoid medications. Under a national community-based mental health program many places in China have started to provide free medications to people with severe mental health disorders in their communities. In the free medication program (FMP) in Liuyang, China, peripatetic psychiatrists prescribed and dispensed antipsychotic medications free of charge at regular intervals and places convenient for all patients through the primary health care system since 2006. Our study aims to test whether adherence to this FMP improves the functioning of people with schizophrenia. Methods The research was conducted in Liuyang, a rural county in central China. Data were obtained from three sources: an ad-hoc survey and the program’s management system in 2013 and in-home interviews in 2014 in Liuyang. We conducted a cross-sectional propensity-score based analysis of the “dose” effect of FMP participation on their level of functioning, using medication refill adherence as a proxy for the participatory intensity in the program. Results Only 50.9% of 2,332 participants came for all refills in 2012. Higher refill adherence was associated with slightly worse functional outcomes. The main reasons for refill non-adherence were “unwilling to take medication or only took medication when unwell” (23.6%), “forgot or missed the appointment” (20.6%) and “hospitalized” (20.1%). Conclusions The FMP program in Liuyang seemed to have successfully removed barriers in cost and access. However, better refill adherence was not associated with better functional outcomes in this study, which might have been the result of reverse causation. To improve the effectiveness of the FMP, patient-centered measures should be considered.

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Section: Discussionsupporting

confidence: 67%

Section: Resultsmentioning

confidence: 99%

The association between a free medicine program and functioning in people with schizophrenia: a cross-sectional study in Liuyang, China

Gong

Zhang

et al. 2020

PeerJ

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“…The 686 Program should develop a guideline on the use of those long-acting injectables, particularly among people with low adherence to pills. We should also note that adherence measured by clinician impression and refill records (the current 686 Program practice) grossly overestimated the level of adherence; the use of simple scales such as DAI-10 or BARS may be considered if home-based pill counts are not feasible [44]. Lastly, we emphasize proper training for the participants on how to receive, read, and reply to text messages.…”

Section: Discussionmentioning

confidence: 99%

“…Due to resource constraints, we used refill records, DAI-10, and BARS instead of pill counts for the measurement of the baseline adherence. The rationale, validity, and details of our methods to measure adherence to antipsychotics in LEAN were published and are publicly available elsewhere [44]. Secondary outcomes were patient symptoms measured by the Clinical Global Impression (CGI) for schizophrenia (which includes 2 scales: CGI–Severity and CGI–Improvement) [45] and patient functioning measured by the WHO Disability Assessment Schedule 2.0 (WHODAS) [46].…”

Section: Methodsmentioning

confidence: 99%

Lay health supporters aided by mobile text messaging to improve adherence, symptoms, and functioning among people with schizophrenia in a resource-poor community in rural China (LEAN): A randomized controlled trial

Xiao

et al. 2019

PLoS Med

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Background Schizophrenia is a leading cause of disability, and a shift from facility- to community-based care has been proposed to meet the resource challenges of mental healthcare in low- and middle-income countries. We hypothesized that the addition of mobile texting would improve schizophrenia care in a resource-poor community setting compared with a community-based free-medicine program alone. Methods and findings In this 2-arm randomized controlled trial, 278 community-dwelling villagers (patient participants) were randomly selected from people with schizophrenia from 9 townships of Hunan, China, and were randomized 1:1 into 2 groups. The program participants were recruited between May 1, 2015, and August 31, 2015, and the intervention and follow-up took place between December 15, 2015, and July 1, 2016. Baseline characteristics of the 2 groups were similar. The patients were on average 46 years of age, had 7 years of education, had a duration of schizophrenia of 18 years with minimal to mild symptoms and nearly one-fifth loss of functioning, and were mostly living with family (95%) and had low incomes. Both the intervention and the control groups received a nationwide community-based mental health program that provided free antipsychotic medications. The patient participants in the intervention group also received LEAN (Lay health supporters, E-platform, Award, and iNtegration), a program that featured recruitment of a lay health supporter and text messages for medication reminders, health education, monitoring of early signs of relapses, and facilitated linkage to primary healthcare. The primary outcome was medication adherence (proportion of dosages taken) assessed by 2 unannounced home-based pill counts 30 days apart at the 6-month endpoint. The secondary and other outcomes included patient symptoms, functioning, relapses, re-hospitalizations, death for any reason, wandering away without notifying anyone, violence against others, damaging goods, and suicide. Intent-to-treat analysis was used. Missing data were handled with multiple imputations. In total, 271 out of 278 patient participants were successfully followed up for outcome assessment. Medication adherence was 0.48 in the control group and 0.61 in the intervention group (adjusted mean difference [AMD] 0.12 [95% CI 0.03 to 0.22]; p = 0.013; effect size 0.38). Among secondary and other outcomes we noted substantial reduction in the risk of relapse (26 [21.7%] of 120 interventional participants versus 40 [34.2%] of 117 controls; relative risk 0.63 [95% CI 0.42 to 0.97]; number needed to treat [NNT] 8.0) and re-hospitalization (9 [7.3%] of 123 interventional participants versus 25 [20.5%] of 122 controls; relative risk 0.36 [95% CI 0.17 to 0.73]; NNT 7.6). The program showed no statistical difference in all other outcomes. During the course of the program, 2 participants in the intervention group and 1 in the control group died. The limitations of the study include its lack of...

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“…However, the fact that a patient has refilled a medication is not a guarantee that the medication is ingested, a fact borne out by numerous studies. 17,18 Pill counts are thus a critical tool for ensuring oral medication adherence. As diversion patients typically meet with a staff member every week, weekly pill counts are an appropriate interval, with the exact day of the week varying (if possible) to avert pill dumping by higher-functioning patients when the assessment day is preassigned.…”

Section: Pill Counts To Track Nonadherence In Schizophrenia Patientsmentioning

confidence: 99%

Monitoring and improving antipsychotic adherence in outpatient forensic diversion programs

Meyer

2019

CNS Spectr.

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Outpatient diversion programs present an opportunity for severely mentally ill defendants to receive psychiatric treatment and have alleged offenses dismissed by the court. Moreover, the successful completion of pretrial diversion is associated with fewer post-program arrest and jail days. The target patient population for such programs is typically people with schizophrenia spectrum disorders, but the care of such patients in outpatient settings presents challenges for monitoring treatment fidelity, specifically antipsychotic adherence, as low adherence rates are associated with increased rates of recidivism. Presented here is a review of evidence-based strategies that must be employed to track antipsychotic adherence in outpatient diversion programs, including pill counts, use of long-acting injectable antipsychotics, and determination of plasma antipsychotic levels to assess adherence and the adequacy of antipsychotic treatment. Antipsychotic therapy remains the foundation of schizophrenia treatment, but only through the use of all available modalities can clinicians maximize the odds that schizophrenia patients in pretrial diversion maintain psychiatric stability and successfully complete mental health court mandates.

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Measuring adherence to antipsychotic medications for schizophrenia: Concordance and validity among a community sample in rural China

Cited by 19 publications

References 70 publications

The association between a free medicine program and functioning in people with schizophrenia: a cross-sectional study in Liuyang, China

The association between a free medicine program and functioning in people with schizophrenia: a cross-sectional study in Liuyang, China

Lay health supporters aided by mobile text messaging to improve adherence, symptoms, and functioning among people with schizophrenia in a resource-poor community in rural China (LEAN): A randomized controlled trial

Monitoring and improving antipsychotic adherence in outpatient forensic diversion programs

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