Predictors of adherence and outcome in schizophrenia

Richard Drake,Senior Lecturer in Adult Psychiatry,

University of Manchester

What I’m Going to Tell You

• Non-adherence predicts poor outcome• Determinants of adherence and

concordance – Insight relates to degree of concordance

• Poor insight predicts poor outcomes– it may predict poor outcome better than

adherence

• Insight and adherence can be changed

Predictors of Outcome in Schizophrenia

• Demographic– Sex, age

• Historical– Premorbid adjustment– DUP, Course of illness– Symptoms

• Behavioural– EE, Substance Misuse – Adherence, Engagement

Predictors of Outcome in Schizophrenia

• Demographic– Sex, age

• Historical– Premorbid adjustment– DUP, Course of illness– Symptoms

• Behavioural– EE, Substance Misuse – Adherence, Engagement

Davis & Andrukaitis 1986 J Clin Psychopharmacol

16.2% 57.6%

Drug Placebo

Davis & Andrukaitis 1986 J Clin Psychopharmacol

Adherence and Chronic Illness

• Stopping APS suddenly: 46% relapse in 6/12 if stable56% in two years

• Stopping gradually: 50% over 2 years

Viguera et al 1997

0

10

20

30

40

50

60

70

80

90

100

Survival (%)

Robinson D et al, Arch Gen Psych, 1999

Gaebel W et al 2002 Sz Res

Gaebel W et al 2002 Sz Res

Wunderink L et al 2005, 2007

MESIFOS STUDY

Determinants of Poor Adherence

• Maybe – isolation, youth and being male– substance abuse – more side effects or their subjective

experience – more frequent doses– Better or worse cognitive function

• Or not, for most of the above

More recent studies

• Internal rather than external locus of control

• High EE family• Poor therapeutic alliance• Negative attitudes • Poor insight

Influence of Others

Belief in Prevention

Medication Affinity

Vauth R et al, 2004 Psychiatry Res

Influence of Others

Belief in Prevention

Medication Affinity

Meaningful Work

Neuro-cognition

Length of Illness

No symptoms

Age

Vauth R et al, 2004 Psychiatry Res

Insight and medication attitudes

Day, J., et al. 2005 Arch Gen Psych 62 717-24

Insight and medication attitudes

Day, J., et al. 2005 Arch Gen Psych 62 717-24

The Construct of Insight

• Insight said to have different dimensions– E.g. recognising sx, illness, its social

consequences, & need for Rx; attributing sx to illness; “hypothetical contradiction”

• Insight appears to have cultural, symptomatic and neuropsychological determinants

Insight and Outcome

• In chronic samples predicts relapse, readmission, symptoms, objective QoL, adherence, other outcomes– perhaps including violence (esp. in short

term or in forensic populations).– Perhaps not including engagement?

• Insight during the process of relapse predicts readmission.

• However, these samples select for poor IS

Why does RLS predict relapse?

• Re-Labelling Symptoms predicts relapse– Unlike accepting NFT, awareness of

illness

• Chance finding?• Related to identifying relapse?• Related to substance misuse, EE?• Related to adherence?

Recent FE naturalistic studies

• Poor adherence in FE– definitions vary but most involve

stopping >7/7 as a minimum– Many of these will stop altogether for

some time– 33% over any 6 months– 42-59% at some point over 1-5years

• All multivariate analyses of predictors of adherence have global insight as significant– Except Coldham et al, 2002

• IS predicts irregular or non-adherence• Disappears when adjust for PM function,

age, cannabis at 1y, family support

Recent FE naturalistic studies

HBM and Adherence in a Trial

• Perkins et al. 2006: FE trial of APS in 254• Small effect of objective SE predicted

non-adherence• Lack of benefit too• Negative attitudes to medication did not• Awareness of benefits of medication in

reducing sx. & NFT both predicted good adherence

IS and Adherence in a Trial

• McEvoy et al. 2006: FE trial of 251 OLZ v HPL

• ITAQ scale predicted time to non-adherence

• Type of medication did not

FE cohorts and trials

• Global IS predicts adherence even after attitudes to medication

• In detail, awareness of past and future symptom reduction predicts continued adherence

• Negativity about medication or perceived SE not predictive; possibly objective SE

• Other aspects of insight inconsistent

Insight may be improved

• Specific IS-focussed CBT may improve it (Turkington et al, 2002, 2006; Rathod et al 2005)

– This form of CBT protected against depression

• Focussed CBT may alter attitudes to illness and self (Gumley et al, 2005)

• General CBT for psychosis may not improve IS or suicidality (Tarrier et al, 2006)

Adherence may be improved

• Psychoeducation about medication almost never effective

• Multi-modal interventions appear more likely to be effective – certainly more fashionable

Insight and medication attitudes

Day, J., et al. 2005 Arch Gen Psych 62 717-24

Adherence may be improved

• Combine education about meds & disorder with:– Behavioural approaches (techniques and

skills, reminders, reinforcement)– Work on therapeutic relationship– Use other interpersonal relationships,

feelings of loyalty etc. (“affective approaches”)

• May be effective individually, in groups or via services (e.g. supported housing)

Summary

• Certain attitudes may be more predictive of future adherence and relapse than current behaviour– There maybe a very disadvantaged

subgroup– Sealing over may predict

disengagement

Summary• Insight is associated with suicidality

– If you then become depressed and hopeless because you’re ashamed and overwhelmed

– It doesn’t help if you abuse substances

• Insight leads to adherence and improvement, which prevents the above

• Specific CBT might improve IS without depression

• Multimodal interventions improve adherence

P D

SE

NFM

+ve correlation -ve correlation

Well

AIS

DSH

Hosp