Non-Adherence to Bipolar Medication: Contributing Factors and Incidence Among Patients

This review article explores the contributing factors and incidence of non-adherence to bipolar medication among patients. The study suggests that younger patients have a higher incidence of non-adherence, and factors such as adverse effects of medication, economic status, and hospitalization history play a role. The article also discusses potential interventions to improve medication adherence.

Running head: BIPOLAR MEDICATION
BIPOLAR MEDICATION
Name of the student:
Name of the university
Author note:
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Methods
The search strategy employed aimed to identify articles that would provide evidence on
the topic of interest, non-adherence to bipolar medication within bipolar patient depending on the
age. The data bases used for the study were EMBASE and PUBMED. The search terms used :
polypharmacy or non, bipolar, mania, patterns of treatment, non-adherence to bipolar medication
and persistence. The finding organized using the PRISMA flow chart ( figure 1).
The eligibility criteria for inclusion study are as follows:
 All articles are taken are peer review journal.
 All Articles are published in English
 All Articles that are extracted on and after the 2013.
 All articles are focused on the non compliance to the bipolar medication
 All articles are focused on the human subjects.
 Articles having the abstracts are included
 Additionally, studies that described non-adherence to pharmacological drugs used to treat
mania and psychosis were included in the study.
The eligibility for the exclusion criteria are as follows:
 All non peer review journal were excluded
 All non English journal were excluded
 All journal focused on the animal model were excluded
 All articles are focused on the non compliance to other psychological disorder other than
bipolar medication can be excluded.
 The articles having clinical guidelines are excluded.
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BIPOLAR MEDICATION
 articles that explained non- adherence to pharmacological treatment for other mental
health disorders were excluded
 Articles that sought to find out strategies of enhancing adherence to bipolar medication,
cost of managing the illness, the burden of the condition, quality and safety of life and
articles that explained non- adherence to pharmacological treatment for other mental
health disorders were excluded.
The total number of 4450 articles was screened from the databases. After screening and
excluding the duplication of the articles 2125 full texts articles were taken which had abstracts.
1800 articles were screened and excluded 1770 articles. Finally, 30 full text articles were further
reviewed for eligibility based on inclusion criteria and out of this , 8 journals were included for
qualitative study.
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PRISMA Flow Diagram
4
Included
Records identified through
database searching
(n = 4450 )
ScreeningEligibility Identification
Additional records identified
through other sources
(n = 0 )
Records after duplicates removed
(n = 2125 )
Records screened
(n = 1800 )
Records excluded
(n = 1770 )
Full-text articles
assessed for eligibility
n=30 )
Full-text articles excluded,
with reasons
(n = 22 )
 strategies of
enhancing adherence
to bipolar medication
 cost of managing the
illness
 the burden of the
condition
 quality and safety of
life
 non- adherence to
pharmacological
treatment for other
mental health
disorders
Studies included in the
qualitative synthesis
(n = 8 )
Studies included in
quantitative synthesis
(meta-analysis)
(n = 0 )

Running head: NON-ADHERENCE TO BIPOLAR MEDICATION
Table of Evidence
EBP Question: Is there a high incidence of non-adherence to bipolar medications among patients and are there any contributing factors?
Student: Elizabeth Mole
Article
Number
Author
and Date
Evidence
Type
Sample, Sample
Size, Setting
Findings That
Help Answer
the EBP
Question
Observable Measures Limitations
Evidence
Level,
Quality
1. Corréard
et al.,
2017
Cross-
sectional
study
n=353, divided
into two age
groups 16-46;47-
71from a French
cohort diagnosed
with BD,
outpatient
psychiatric clinic
Poor
adherence to
medication is
universal in
bipolar disorder
and is
associated with
several
factors.such as
 Standardized
clinical and
neuropsychologi
cal assessment
screening tools
 Medication
Adherence
Rating Scale
 The absence of a
control group for the
effect of natural aging
require further
longitudinal studies
 Selection bias
 The use of the
stepwise backward
selection procedure
Level I,
A
2. Cutler et
al., 2018
Systematic
review
79 studies, a
comprehensive
literature search
was conducted in
PubMed and
Scopus in
September 2017
Medication
non-adherence
among patients
with bipolar
disorder is
correlated with
higher disease
prevalence.
 Relevant
information was
extracted, and its
quality assessed
using the
Drummond
Checklist tool.
 Inability to perform a
meaningful meta-
analysis
 Insufficient statistical
data and
considerable
heterogeneity
according to
outcome/indicators.
Level I,
A
3. García et
al
.,
2016.
Systematic
review
An electronic
search in the
PubMed
database from
1990–2015 of
MeSH terms:
medication
adherence,
antipsychotic
agents, mood
The study
indicated that
approximately
42% of patients
diagnosed with
bipolar disorder
do not adhere
to medications
prescribed.
 The Basque
Office for Health
Technology
Assessment Tool
was utilized to
screen data for
quality.
 A wide range of rates
of adherence found in
the scientific literature
 High rates of
subjective reports
 Biased reporting of
objective measures
Level I,
A
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disorder,
psychotic
disorder, and
bipolar disorder
4. Goldstein
et al.,
2016
Non-
randomized
controlled
trial
n=21
adolescents with
a primary BP
diagnosis,
pediatric
specialty clinic
Findings detail
evidence of
poor
medication
adherence
among youth
with bipolar
disorder, and of
the subjective
report of
adherence.
 MedTracker data
on adherence
with the
subjective
reports
 Binary logistic
regression
 Spearman
correlation
coefficients
 Misrepresentation of
accurate adherence
rates due to
modification of
behavior in response
control group
awareness of being
observed
 Accuracy that the
subject ingested the
medication
 Small sample size
Level II,
B
5. Levin et
al., 2017
The NIMH-
funded
randomized
control trial
n=73 patients
with bipolar
disorder and
medical
comorbidities,
outpatient
psychiatric clinic
Medication
treatment
regimen, sex,
ethnicity, and
specific bipolar
disorder
symptoms have
a direct
correlation with
adherence to
medications.
 Factors of the
MADRS and
BRPS
psychiatric
scales
 Statistical
analyses were
performed using
IBM SPSS
Statistics 22
 Sample bias thus
impacting
generalizability of the
results
 Small sample size
 Reliability of
subjective reports
Level I,
B
6. Levin et
al., 2015
Two
prospective
uncontrolled
trials
Patients
diagnosed with
bipolar disorder,
n=43 for cohort
1, n=43 for
cohort 2,
community
Findings
indicate an
inverse
relationship
from baseline
non-adherence
and response
 Tablets Routine
Questionnaire
(TRQ), Attitudes
toward Mood
Stabilizers
Questionnaire
(AMSQ)
 Relatively short-term
follow-up
 Uncontrolled design
 Small sample size
 Limited assessment
of other patient-
related factors
Level II,
B
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mental health
center.
to an
adherence
enhancement
intervention.
Findings also
suggest
individuals who
were most non-
adherent may
benefit from
stronger
interventions
 Brief Psychiatric
Rating Scale
(BPRS)
 Hamilton
Depression
Rating Scale
(HAM-D)
 Young Mania
Rating Scale
(YMRS)
 Data were
analyzed using
SPSS
7. Mert et
al., 2015
Cross-
sectional
study
Patients
hospitalized with
bipolar disorder,
schizophrenia,
schizoaffective
disorders,
depression, and
other psychiatric
disorders,
patients receiving
treatment
between October
2013 and
February 2014,
University
inpatient
psychiatric unit
Medication
nonadherence
affects
treatment
success
significantly
more in bipolar
disorder and
has a direct
correlation to
poor follow up
appointments
after
hospitalization.
 SPSS evaluated
data
 Specially
designed form to
collect data was
used
 Limited setting
 Unreliable sample
size
 Cross-sectional study
Level III,
B
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8. Ralat,
Depp, &
Bernal,
2017.
Qualitative
study
n=22 adults ages
23-60 who had
BD, Type I/II and
CVD risk factors,
three focus group
sessions,
medical clinic
Latino patients
have a high
incidence of
non-adherence
to bipolar
medications
and treatment.
 Audio-recordings
of focus groups
were transcribed
 Content analysis
was done
 Generalizability of
results
 Small sample size
 Reliability of
subjective reports
Level III,
B
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Findings
In the current review, studies were evaluated for quality using the Johns Hopkins Nursing
Evidence-Based Practice leveling system. The Johns Hopkins Nursing Evidence-Based Practice
structure consists of five rating levels (Dang & Dearholt, 2017). The data were extracted for
each of the eight papers and a review of author and date, evidence type, findings, sample and
setting, limitation, observable measures, and data quality was done. From the deduction of the 8
full-text journals eligible for inclusion criteria, it was observed that the incidence of
nonadherence is higher in the case of younger patients. A cross-sectional study by Corréard et al.
(2017), suggested that after bipolar medication the neuropsychological performance of the
younger patient is better compared to the elder patient. However, the incidence of the
nonadherence to the bipolar medication is high which is influenced by various factors. One of the
important factors that observed by the study is the high adverse effect of the medication which
acts as the risk factor for the non-adherence, especially in a younger patient (García et al.,
2016). However, the limitation of the study is that the researchers were biased towards the
patient while selecting the patient and they did not consider the effect of natural aging. Another
study suggested that lifetime hospitalization is another risk factor of low adherence to the bipolar
medication regardless of ages. However, it was also found that the longer hospitalization also
associated with learning effect but in a young bipolar patient, the adherence is still low due to the
short illness. The study by Goldstein et al. ( 2016), Suggested the patient with current depression
due to bipolar and cocaine-dependent shows that they have baseline cognitive functioning and
high adherence to the bipolar medication. Interestingly, the decline of prospective memory is
associated with the high incidence of non-adherence mostly in the older patient (Levin et al.,
2017). The one possible explanation of this phenomenon is age-related impairment is associated
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with the deterioration of the frontal lobe. However, further studies needed for the efficacy of the
interventions such as combination the cognitive remediation through the therapy and biological
medications (Levin et al., 2015). Another systematic review by Cutler et al. ( 2018), the
incidence of non adherence is directly associated with the economic status of the individual
irrespective of the age. Due to the high expenses of the bipolar medication, a bipolar patient with
lower social economic status does not seek the help of medication (Mert et al., 2015).
Subsequently, the non-adherence incidence is high. Sometimes the patient prefers cognitive
therapy due to the high cost of antipsychotic medicines (Levin et al., 2015). Therefore, the
adherence is low for the bipolar medication in the patient with a lower socioeconomic status.
Moreover, the studies Ralat, Depp, & Bernal (2017) shows that the use of the antipsychotic
medication give rise to the higher risk of cardiovascular disease and therefore the incidence is
high. The age adoptive therapeutic interventions to improve medication adherence (Ralat, Depp,
& Bernal, 2017). Thus, it can be concluded that the high adherence to the bipolar disorder can be
achieved if the intervention plan designed on the basis of the economic status of the patient, the
health status of the patient, age and the amount of administration of the medicine (Mert et al.,
2015)..
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References :
Corréard, N., Consoloni, J. L., Raust, A., Etain, B., Guillot, R., Job, S., ... & Fredembach, B.
(2017). Neuropsychological functioning, age, and medication adherence in bipolar
disorder. PloS one, 12(9), e0184313.
Cutler, R. L., Fernandez-Llimos, F., Frommer, M., Benrimoj, C., & Garcia-Cardenas, V. (2018).
Economic impact of medication non-adherence by disease groups: a systematic
review. BMJ open, 8(1), e016982.
Dang, D., & Dearholt, S.L. (2017). Johns Hopkins Nursing Evidence-based Practice Third
edition: Model and Guidelines. Retrieved from http://ebookcentral.proquest.com
García, S., Martínez-Cengotitabengoa, M., López-Zurbano, S., Zorrilla, I., López, P., Vieta, E.,
&González-Pinto, A. (2016). Adherence to antipsychotic medication in bipolar disorder
and schizophrenic patients: a systematic review. Journal of clinical
psychopharmacology, 36(4), 355.
Goldstein, T. R., Krantz, M., Merranko, J., Garcia, M., Sobel, L., Rodriguez, C., ... & Birmaher,
B. (2016). Medication adherence among adolescents with bipolar disorder. Journal of
child and adolescent psychopharmacology, 26(10), 864-872.
Levin, J. B., Krivenko, A., Bukach, A., Tatsuoka, C., Cassidy, K. A., & Sajatovic, M. (2017). A
reexamination of non-psychiatric medication adherence in individuals with bipolar
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disorder and medical comorbidities. The Journal of Nervous and Mental disease, 205(3),
182.
Levin, J. B., Tatsuoka, C., Cassidy, K. A., Aebi, M. E., & Sajatovic, M. (2015). Trajectories of
medication attitudes and adherence behavior change in non-adherent bipolar
patients. Comprehensive Psychiatry, 58, 29-36.
Mert, D. G., Turgut, N. H., Kelleci, M., & Semiz, M. (2015). Perspectives on reasons of
medication nonadherence in psychiatric patients. Patient Preference and Adherence, 9,
87.
Ralat, S. I., Depp, C. A., & Bernal, G. (2017). Reasons for Nonadherence to Psychiatric
Medication and Cardiovascular Risk Factors Treatment Among Latino Bipolar Disorder
Patients Living in Puerto Rico: A Qualitative Study. Community Mental Health Journal,
1-10.
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