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

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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

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AIS

DSH

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