Exploring Factors Affecting Medication Adherence in Bipolar Disorder

This dissertation investigates the multifaceted factors influencing medication adherence in individuals diagnosed with bipolar disorder. It begins by defining bipolar disorder and highlighting the challenges of long-term treatment, emphasizing inadequate adherence as a significant obstacle. The literature review explores the concept of medication adherence, its impact on individuals with bipolar disorder, and strategies for improvement. Key themes include the significance of adherence for effective pharmacological response, the distinction between adherence and persistence, and the consequences of non-adherence, such as worsening conditions and increased healthcare costs. The study also addresses reasons for non-adherence, including lack of awareness, substance abuse, poor patient-psychiatrist relationships, medication side effects, and fear of hospitalization. Furthermore, it examines patient-related factors like co-morbid conditions, family history, and financial constraints, along with the role of medication possession ratio (MPR) in monitoring adherence. The dissertation identifies key domains influencing adherence, including doctor-patient relationship, medication effects, and patient beliefs, while also considering affordability, mental health stigma, family influence, and cultural beliefs as critical factors. This document is available on Desklib, a platform offering a range of study tools and resources for students.

Dissertation

Table of Contents
TITLE..............................................................................................................................................1
CHAPTER ONE: INTRODUCTION (1500)..................................................................................1
CHAPTER 2: LITERATURE REVIEW (3000).............................................................................2
Theme one: Concept of medication adherence in individuals with bipolar disorder.............2
Theme two: Effect of medication adherence in individuals with bipolar disorder................7
Theme three: Ways or strategies to improve factor that influence the medication adherence in
individuals with bipolar disorder............................................................................................9
CHAPTER 3: RESEARCH METHDOLOGY (3000)..................................................................10
Research Approach (200 words)..........................................................................................10
Primary Research (200 words).............................................................................................10
Secondary Research (200 words).........................................................................................10
Type of Review (150 words)................................................................................................10
Critical review (200 words)..................................................................................................10
Traditional (narrative) review (200 words)..........................................................................10
A Systematic review (200 words)........................................................................................10
Research Paradigms: Positivist and Interpretivist (200 words)............................................10
Methods of Qualitative Research and Their Relationship to Critical Review (250 words). 10
Inclusion and Exclusion Criteria (500 words)......................................................................10
Search Strategy and String...................................................................................................10
Search strategy)- (300 words)..............................................................................................10
Search string (150 words).....................................................................................................10
Database Search Method (400 words)..................................................................................10
Data Extraction (300 words)................................................................................................10
Issues of Good Practice (150 words)....................................................................................10
Ethics (150 words)................................................................................................................10
Research Limitation (150 words).........................................................................................10
CHAPTER 4: FINDING AND DISCUSSION (2500)..................................................................10
REFERENCES..............................................................................................................................13

TITLE
“Factors influencing medication adherence in individuals with bipolar disorder”
CHAPTER ONE: INTRODUCTION (1500)
The bipolar disorder is defined as the aspect which is commonly show the prevalent and
enduring condition which is majorly characterized by the current episode and often show the
aspect which is followed to make the residual symptoms. The high rate of the comorbidity,
suicide and the functional impairment which is well related with the bipolar disorder which
ensure that it is usually a common cause of the disability as well as the economic and the social
burden (Crișan, 2018). The pharmacological treatment which is well related with both acute and
long-term treatment with the bipolar disorder in the term of clinical trials of such medication. In
addition to this, the effectiveness of the medication is well focused on the aspect which is usually
provide the aspect which is related with the long-term treatment with the context to medication
which is less impressive in the routine basis. Therefore, the analysis also focuses on the aspect
which is related with the inadequate treatment adherence which is defined as the single most
important hurdle and challenge which is based on the translation efficacy in the setting for
research. In common with the other chronic medical situation with the intermittent symptoms
and they are showing the delay response of the proper discontinuous of the treatment (Foley and
et. al., 2021).
The effectiveness of the medication while providing the treatment are usually associated
with the long-term effect but usually sometimes, they show various side effect and adverse effect
that can create complications with the patient while taking the drug in the treatment of bipolar
disorders. In common with other chronic medical condition with the various symptoms they
usually show delay effect of the treatment due to the adherence that is caused due to the drug in
the bipolar patient (Gromisch and et. al., 2020). Apart from that the useful aspect of treatment
and leading to show the poor outcome are usually associated with the medication that are not
effective as enough to provide therapeutic effect as comparison to other drug in the bipolar
disorder on the peak potential. There is various aspect which is also showing that the medication
which is used in the prescription for the bipolar disorders are usually adhere with the various
complications. Such as, they are showing drug-drug interaction, drug food interaction and many
more. Adherence is defined as the extension which is usually based on the person behaviour
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taking medication follow that diet which is appropriate in order to execute the lifestyle changes
that is helpful to recommend a healthy approach towards, they are health complications and the
instruction are usually followed by health care provider to the service user (Strejilevich and et.
al., 2019).
CHAPTER 2: LITERATURE REVIEW (3000)
Theme one: Concept of medication adherence in individuals with bipolar disorder.
Medication adherence is an important factor for effective pharmacological response. The
term medication adherence consists of two terms “adherence” and “persistence”. The treatment
and its adherence in individuals with bipolar disorder can vary from person to person. Failing to
adherence to medication prescribed by the medicinal practitioner can lead to severe
consequences such as worsening of bipolar condition if left untreated, increased cost of
healthcare in future and even death. The risk of dementia is high for patients with a history of
bipolar disorder. For patients with bipolar disorder sometimes adherence can be partial, complete
or sometimes none depending on the mood stability of the patient (Factors influencing
medication adherence among patients with severe mental disorders from the perspective of
mental health professionals,2022). According to Mayo health clinic, 50% of the prescriptions are
not completed by the patients suffering from bipolar disorder. The medication compliance can be
associated with non-adherence, safe to say it is a form of medical non adherence.
Noncompliance is when a patient intentionally refuses to administer the medication. This results
in a significant decrease in patient's health quality. The most significant reason of non-adherence
in patients with schizophrenia and bipolar disorder is the lack of awareness about the disease,
this is termed as anosognosia where a person is unaware about their illness and continues to
believe that they are healthy and fit (Gershonand et. al., 2019). Other reasons can include
continues alcohol and substance abuse which can lead to forgetfulness and sometimes when a
doctor suggests withdrawal from alcohol, patient tends to skip medication in order to drink.
There are several studies that show the relationship between substance misuse and medical non
adherence. Persistent consumption of alcohol can lead to impaired mental state and therefore it
can cause medical non adherence. A poor therapeutic alliance between a patient and their
psychiatrist can be a prime reason why a patient is non adherent, this can also be seen as a
management approach towards bipolar disorder, to work on the relationship between patient and
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counsellor. This can include language barrier, bad behaviour of the doctor towards a patient,
nurses and social workers. Stronger interactions can lead to proper medical adherence and
reduction in frequent depressive episodes (Inder and et. al., 2019). The side effects of
medications prescribed and an increased fear of addiction can lead to a patient not following the
complete adherence.
Patients with bipolar disorder often suffer from the fear of hospitalization and stigma
involved around the treatment of mental illness. In case of patients suffering from bipolar
disorder it was also observed that they stop consuming medicines because they enjoy being a
manic. The three main factors influencing medication adherence are a) attitude towards the
illness b) insufficient aftercare, and c) shortage of resources. Conditional factors such as poly
pharmacy, co-morbid situations (presence of both mental and physical health conditions) creates
a sense of dilemma and promote poorer medication. Patient related factors such as presence of
other diseases, menopause in women, family history and low literacy rate can affect medication
intake severely (Marrero and et. al., 2020). Patients living in farmlands and outskirts of the city,
where there is poor accessibility to healthcare, can go undiagnosed and sometimes do not bother
buying medicines and completing their medication course. The financial conditions of the
patients must be taken into consideration when prescribing expensive drugs as they influence the
livelihood of the individual and therefore, they won't stick to their medication routine. High
treatment costs mostly affect medical adherence. High dosing frequency affect the ability of
patient to stick to medical adherence. For example, if a drug is to be administered 6 times a day a
patient might get fed up of continuously consuming the medication and therefore will not adhere
the routine.
In bipolar patients with lower antipsychotic adherence there is an increased risk of relapse
and even increased risk of suicide so interventions to make an improvement in adherence can
lead to decreased risks and better quality of life. In order to improve this condition creating
awareness about the disease, forming a strong bond with patients, simplifying medication
routine, prescribing low dose frequency is important (Medication nonadherence in bipolar
disorder: a narrative review, 2018). These sudden relapses can increase the impact on work-life
balance, strained personal relationships. An individual with specific traditional beliefs and
knowledge can stop taking medications due to unwanted influence of others, other factors
include lack of emotional support from family, difficulty remembering frequency of dosing
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medication. The cost of healthcare treatment around the country has significantly increased
making it more difficult for people of low economic background Medical health plans can help
under privileged people get the advantages of medications. Failure to compliance results in
frequent hospitalizations, increased emergency room visits and early possible death. Bipolar
disorder has most suicide rates out of all psychiatric disorders, depressive episodes and manic
behaviour leads to such extremities. The annual price to the National Health Service (NHS)
within side the UK changed into predicted to be £342 million at 2009/2010 prices, with 60% of
this accounted for via way of means of inpatient admissions. Medication possession ratio (MPR)
is a method by which medication adherence can be monitored by the number of prescription
refills at the pharmacy (The relationship between antipsychotic medication adherence and
patient outcomes among individuals diagnosed with bipolar disorder: a retrospective study,
2009). The attitude towards medication for bipolar disorder adherence was studies more in
women than in men. Men who had high masculinity attitude are mostly non adherent because
men are studied to be too proud to take any medications. If medical non adherence is not
identified by the pharmacist or doctor and is assumed wrongly and with addition of new
medicines that may result in further non adherence.
Medical adherence provides the efficacy effectiveness gap of medication for patient related to
bipolar disorder. There are number of factors in case of bipolar disorder which influencing
medical adherence. The factors which influence the medical adherence can be vary from one
person to another person and it may be complex often. Medical adherences associated Lithium
treatment for bipolar disorder are divided into four key domain that have a role in people persist
with their medication (Bagadia, et. al., 2020). That four key domains are:
 The doctor
 The patient
 The medication effects
 The illness
These are the four factors which influence the medical adherence of bipolar disorder other than
these, several other factor also influence the medication adherence in bipolar disorder like, the
patient attitude toward their medication influenced by the side effect, complexity or severity of
the disease experienced by the patient and also influencing by the relationship between the
4

doctor with their patient. There are number of another factors which play their role in medication
adherences of bipolar disorders. These factors are mentioned below:
 Affordability: Higher cost of treatment of bipolar disease becomes most common barrier
in the case of bipolar diseases. Many of patient associated with this issue cannot get
appropriate medication due to lack of insurance or unable to pay the cost of treatment of
this disease.
 Mental health stigma: There are stigma associated with mental disorder in our society
therefore, patient suffering from mental disorder have make a fear in their mind for
negative opinion of other people. By which they influence for either not taking the
appropriate medication for mental illness or not following the instruction given by the
doctor about their medication (Bart, et. al., 2021).
 Family Influencing: Family behaviour toward the mental patient have important impact
in their medication adherences. Like, supportive behaviour of family influencing the
patient to take their treatment at time and according to the prescription but unsupportive
behaviour leads toward medication non-adherences in case of mental disorder. Poor
support, family dysfunction, negative attitude and criticism towards the treatment
promotes for non-adherence of treatment in the case of bipolar disorder (Cegla-
Schvartzman, et. al., 2019).
 Belief about medication: attitude of person and their belief about the Bipolar
medication can affects their willing for, either sticking with the treatment of their bipolar
disorder and doctor's recommendation or not. Some of the negative attitudes that that
influence the believe toward the non-adherence in their treatment of bipolar disorder,
like:
1. They believing that treatment is not effective for their disorder.
2. They fear about the side effects of treatment.
3. Have a fear, that they have to become dependent on another person.
4. Fear of losing independence or being controlled by another.
5. Thinking likes, symptoms are not severe as much as it required to take medication or
treatment.
6. Missing some symptoms associated with these disorder.
These all attitudes of patients lead towards the non-adherence of medication of bipolar disorder.
5

 Satisfaction with treatment: overall satisfaction of people to their treatment also influence
the patient either to sticking with bipolar disorder's medication or not. People who doesn't
have any bad experience of side effect about their medication are showing longer
adherence with their disorder's treatment. But, those who feels that their treatment does
not showing any medication effects and are likely to discontinue their treatment.
 Lack of knowledge about bipolar disorders: lack of knowledge about these mental
disorder can interrupt to stick with their treatment schedule. When people does not
understand the symptoms of bipolar disorder then they generally not getting any
treatment for their symptoms. Lack of knowledge regarding the disorder can create the
communication gap between doctor and patient which influence the non-adherence
towards the effective medication (Umeoka, et. al., 2020).
 Age related factor: Generally adult people are more careful about their medical treatment
or symptom showing in mental disorders rather than the older people. Older people are
unable to identify their symptoms regarding mental disorder either due to lack of
knowledge or fear of independency (Fabbri, 2020).
 Measure of intake complexity of dosages form: like several people do not have any idea
about measure of dosage form about their medication that is how many number of tablets
have to take, frequency of medication intake and so on. Lack of knowledge about
duration of therapy, duration of disorder, insurance status & medication status.
Alcohol consumption create high risk for medication non adherent rather than non-alcohol
users. Smoking habit also influenced the medication adherence because heavy tobacco smoking
affects the cells of brain and can cause the symptoms like loss of memory which may lead to
miss the dosage of medication during treatment. Disorder regarding factors like patient does not
know about the pathophysiology of the mental disorder. Availability of knowledge of disorders
and their treatment in society also influenced the treatment adherence or non-adherence of
bipolar disorder (Madsen, et. at., 2021). social support with patient promote medication
adherence in these case. Some demography and clinical variables like young age, severity of
symptoms, knowledge of medical clinical personnel affect the adherences of medication during
bipolar treatment. Patient ability to take decision for their own treatment or to continue their
treatment through them on belief, perceptions for benefits and the side effects of treatment.
patient and family’s education, behaviour, believe and their perception regarding the disorder can
6

lead toward adherence or non-adherence of medication for bipolar disorders. Therefore, factors
like patient related, medication related, age, sex, education about the bipolar disorders, stigma
regarding disorders, fear of society, fear with side effect and forgetfulness associated with the
treatment leads to medication non-adherence (de Carvalho Lima, and Fries, 2022) .
Theme two: Effect of medication adherence in individuals with bipolar disorder.
Social and economic factors: Patient suffering from bipolar disease is unable to received
medication information and understand dose regimen properly. So person taking care of the
patient is responsible to memorize complete information regarding medication schedule and
assuring continue administration of drug by patient without any mistakes. Stigma is also a reason
for non-adherence, patient don't want anyone in society to know about their mental problems.
Patients prefer to discontinue their medicines, when find place inappropriate to take medications
due to fear of watching by anybody. Sometimes patients have tendency to prefer alternative
remedies like Homeopathic or Ayurveda one instead of conventional medicines. As they believe
to get treated with bipolar disease quickly and effectively by adopting natural methods with less
or no side effects. Medication mismanagement may be led by prioritize religious rituals above
medication schedule, for instance, fasting during Ramadan or any other occasion results in
discontinuing medicines for a certain period of time (Ansari, and et. al., (2020). This factor
includes logistical and financial barriers like cost of medicines, shortage of medicines, logistical
problems, renewal of medicines and lack of resources, that we are going to focus here.
Employment have an effect on medical adherence due to tight working schedules.
Unemployment leads to lack of money which also prove to be a barrier to stick to the medication
of bipolar disease. Financial burdens and high cost to medicines are significant barriers to
medication adherence as patients from low economic status are unlikely to make medicines
priority over clothing and food. In developing countries, shortage of medicine availability and
difficulties to travel to far distance just to take medicines can hinder good medication
management.
Therapy- related factors: In hope of getting positive results in minimal time; sometimes
patient suffering from bipolar disease become impatient and patient start to switch for alternative
available therapies and does not stick to any particular medication and therapy schedule
(Consoloni, and et. al., (2021). It is important to have good relationships between patient and
treatment provider in order to provide effective patient counselling and act as a helping hand to
7

fight with existing bipolar disease. Good and trust worthy relationships help patient to discuss
freely about side effects, mood swings and maniac episodes they face during or after taking/
missing medication. Warnings of side effects mentioned in leaflet (come along with medicine
package) make a patient decide to not take the medicine. Some patients have attitude of
controlling their life by self may lead them to take self-medication instead of prescribed one.
Patient related factors: Education plays a vital role in informing people regarding
importance of any disease (Edgcomb, and Zima, 2018). Education make people aware about
physical and mental disease, how much it is important to get rid of any specific disease like
bipolar disorder, methods of intervention, importance of taking drug on scheduled time and
importance of follow prescription given by professional medical practitioner. Patient's poor
awareness regarding the need and dose regimen tend them to adjust their dose according to their
understanding and self-satisfaction. Lack of motivation is a general feeling in bipolar disease
patients, they feel that they cannot control this disease hence stop taking medications. A lack of
routines, being busy in working schedules, though of being stigmatization, or erroneous belief
regarding medication are the risk points for medication adherence and lead to missing doses.
Fear of suffering pain and feeling unpleasant from injectable drugs make patients to avoid anti
bipolar drugs. In case of old-age patients, they are physically dependent on someone else for
drug administration as they have weak eyesight and weak body to take medicines by themselves
(Hassan, and et. al., (2019). Illiterate patients are unable to read prescriptions increases the
adherence problem. As well unsuitability to understand any language other than mother tongue
make it difficult to read and understand the prescription. Comorbidity is also a major factor.
Healthcare system factors: Improper access to healthcare and long waiting times cause
poor medication adherence. Lack of communication and co-ordination between doctor,
pharmacist, and patient's care taker can results to cause problems in treatment of bipolar disease.
Lack of support and empathy from healthcare providers negatively impact decision of bipolar
patients to be adhered to the medication. It is important as well as responsibility of healthcare
professionals to discuss importance of adherence and negative impacts of missing drugs with
patients (Jawad, and et. al., (2018). And make them understand that taking their concerns and
experience seriously by themselves can impact the efficacy to a good extent. Patient's adherence
behaviour is also influenced by lack of faith and trust towards their doctor. And having any doubt
8

regarding healthcare professional's experiences may enhance the burden of illness (Kar, and et.
al., (2021).
Theme three: Ways or strategies to improve factor that influence the medication adherence in
individuals with bipolar disorder.
Bipolar disorder is a mood disorder which is recognized by mania, depression and
hypomania. It is analysed that 1.3% of population of UK is suffering from this disease. Bipolar
disorder causes cognitive impairment and also leave a bad impact on an individual quality life.
This disease requires a complex medication which is not always helpful for everyone.
Appropriate adherence to medication can enhance effectiveness of the treatment. Common
challenges faced by people suffering from bipolar diseases are cost, understanding the diagnosis,
dealing with stigma of being a mental patient and managing the treatment. Early identification of
factors related to non-adherence can minimize the risk factor.
Strategies:
 Pharmacologic strategy: There is requirement of complex medication in patient with
bipolar disorder. Due to complex medication adherence becomes more difficult.
Administration of daily dosing is preferred for consistency and to maintain the serum
concentration. In bipolar disorder antidepressant is controversial. Novel extended release
antidepressant formulations are used. Only 50% of patient with bipolar disorder are stick
to atypical antipsychotics. Long acting injectable drugs are used to minimize the
occurrence of non-adherence.
 Psychological strategies: The focal point of this strategy is psycho education,
interpersonal and society rhythm therapy. Psycho-education decrease the risk of
deterioration, hospitalization and improve medication adherence.
Aims of strategies:
 To understand patient perception about the treatment during the diagnosis.
 To support people with bipolar disorder.
 To determine the efficacy of the treatment.
 To remove the stigma of mental health.
 To start a novel innervation to target a medical adherence.
 To explore current understanding of patient behaviour and hoe theories can be applied to
adherence.
9

 To reduce the occurrence of non-adherence
CHAPTER 3: RESEARCH METHDOLOGY (3000)
Research Approach (200 words)
Primary Research (200 words)
Secondary Research (200 words)
Type of Review (150 words)
Critical review (200 words)
Traditional (narrative) review (200 words)
A Systematic review (200 words)
Research Paradigms: Positivist and Interpretivist (200 words)
Methods of Qualitative Research and Their Relationship to Critical Review (250 words)
Inclusion and Exclusion Criteria (500 words)
Search Strategy and String
Search strategy)- (300 words)
Search string (150 words)
Database Search Method (400 words)
Data Extraction (300 words)
Issues of Good Practice (150 words)
Ethics (150 words)
Research Limitation (150 words)
CHAPTER 4: FINDING AND DISCUSSION (2500)
A disease which is associated with the episodes of mood swings ranging from depressive
lows to high manic often followed by residual symptoms. When diagnosed with Bipolar disorder,
about half of the patients become non-adherent during long term treatment (Bauer and et. al.,
2019). There are various factors influencing medications that shows adherence in individuals to
10

bipolar disorder. Non-adherence increases the risk of relapse, disapproval and structural damage,
re-hospitalization and self-destructive terrible folds. Non-adherence in individual's in BD can
lead to greater usage of health care services and increased mental health spending. Finally
leading to poorer quality of life, adding burden on the family and the society as well. For
example, patient related issues have come to personal attitudes and beliefs about medication
taking in addition to statistic factors. In the 1980s and 1990s research in treatment non-adherence
amongst those diagnosed with psychiatric disorder including BD mostly limited itself to
examining statistical growth, clinical and medication related factors medication affecting
adherence. Among demographic evidences there has been some evidence for an association of
non-adherence in BD with younger age, minority ethnicity, and social disadvantage but the links
to such evidences are either limited or unsupportive The role of clinical factors in determining
non-adherence in BD seems to have similarly inconsistent and indeterminate. Overall severity of
the disorder in terms of symptom burden, greater number of mood swing episodes and prior
hospitalization appeared to non-adherence in some. There were several studies done among the
patients and that concluded to poor insight and denial of the illness was associated with the non-
adherence (Chakrabarti, 2018).
However, it might be difficult for the patient for a patient to be adhesive without a basic
level of insight, simply insight or penetration may not be sufficient to ensure adherence. High
dosing frequency affect the ability to patient to stick to medication adherence. The higher
prevalence of non-adherence during maniac episodes could well be due to a lack of insight or the
presence of psychological feature impairment (Davarinejad and et. al., 2021). Here in this
context unintentional non-adherence arises from personal or environmental boundations which
hamper the medication taking, while intentional non-adherence arises from patients. Some of the
studies have concluded that the adverse attitudes and health beliefs on patients have a much
greater impact on non-adherence than demographic, illness or treatment related factors such as
side effects. In other factors such as doubts about the need for medication, as well as their
adverse effects have been found to account for a significant magnitude of deviation in non-
adherence. Apart from attitudes and health beliefs the other principal also influence on non-
adherence in BD is the treatment-alliance between the doctors or clinicians and patients. There is
a concept of the treatment-alliance as a cooperative and very affective bond between the doctors
and the patient has its origin in psychotherapy and psychotherapeutic literature. In making with
11

the research evidence on treatment-alliance in psychiatric disorders such as schizophrenia, an
effective alliance appears to have a significant influence on treating non-adherence in BD as well
(Greene and et. al., 2018).
It can be seen that there is another potential crucial factor of adherence in BD is the
knowledge about the illness and its treatment among patients. Lacking to such knowledge is far-
flung and a predominant source of dissatisfaction among patients. Patients with BD are often
seen particularly unhappy with the lack of information provided on side effects and other aspects
of medication treatment. Insufficient knowledge could be due to insufficient efforts and
ineffective means of transmitting information by clinicians, as well as psychological feature
impairments, lack of insight and motivation among patients. Patient develop perception about
their need for information and the extent to which these are met also have some relatedness on
adherence. Families also plays an influencing role in patient medication adherence in several
ways (Lee and et. al., 2019). A disorganised or dysfunctional family environment has been
associated with higher prevalence of non-adherence in BD. A disturbed family atmosphere often
leads to non-adherence by reduction in social support to the patient. Such a result is more often
seen among the patients who are more with a greater outer site of control are more likely to
become non-adherent. Criticism, negative affective responses and stigmatization or rejection
within the family are also associated with non-adherence among the patients with BD.
Ultimately, attitudes and health-beliefs of family members and their knowledge of the illness and
treatment have been shown to have a significant influence on the patient’s own beliefs and
attitudes. Accordingly, negative attitudes and improper understanding of the illness among the
family members may affect the patient's decision whether or not to continue treatment. For many
people with BD, the stigma of having a chronic mental illness and needing to take long-term
treatment for it may be discouraging adherence. Feelings of stigma regarding BD and its
treatment also promote negative attitudes towards treatment has been found to be a crucial of
non-adherence in BD. Dissatisfaction with the efficacy of treatment, with lack of information,
with practitioner and with the treatment-alliance have all been found to adversely affect the
adherence in BD. Access to treatment and affordability of treatment also comprise significant
barriers to continued adherence in BD because of systemic barriers to gaining access to
appropriate care (Radwan and et. al., 2020).
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