Updated strategies for the management of poor medication adherence in patients with bipolar disorder

ABSTRACT

Introduction

Suboptimal adherence is a well-established, pervasive problem in individuals with bipolar disorder (BD) causing disability, suffering, and cost.

Areas Covered

This review covers new research since January 2016 regarding internal (patient-centered) and external (system level) barriers and facilitators to adherence. Measures of adherence, the efficacy of psychosocial adherence enhancement interventions in individuals with BD, and, finally, novel delivery systems for BD medication are also covered. Measures of adherence continue to fall broadly into objective measures (i.e. drug levels) and more subjective, self-report measures and a combination of these likely provides the most comprehensive picture. Efficacious components of psychosocial adherence enhancement interventions include psychoeducation, motivational interviewing, and cognitive behavioral strategies, yet methods for delivery vary. Long-acting injectable (LAI) medications for BD are the drug delivery system with the most promise for BD. Combining psychosocial components with novel drug delivery systems has the potential for establishing and maintaining medication adherence.

Expert opinion

Psychosocial interventions improve adherence in individuals with BD. Psychoeducation is a necessary but not sufficient component in psychosocial interventions. LAIs should be considered earlier for adherence improvement than many treatment guidelines currently suggest. Comparative studies are lacking as is research into novel systems of medication delivery.

KEYWORDS:

• Bipolar disorder
• adherence
• intervention
• medication treatment
• psychosocial

Article highlights

• Suboptimal medication adherence is a multifaceted problem and target for intervention to improve clinical outcomes for individuals with bipolar disorder.

• Given the many challenges of using either subjective or objective methods for assessing medication adherence, it is recommended that a minimum of two methods be used with at least one that quantifies the proportion of medication missed.

• Targets for adherence enhancement interventions should include patient-specific, treatment-specific, and system-specific barriers.

• Efficacious psychosocial treatment elements of adherence enhancement interventions with at least moderate evidence include psychoeducation, brief motivational interviewing, medication reminders, and cognitive behavior strategies, which target specific barriers.

• Long-acting formulations dosed less frequently and simplifying medication regimens yield better adherence.

This box summarizes key points contained in the article.

Conflicts of interest

Jennifer Levin receives partial salary support from the following research grants: the National Institutes of Health (NIH) and the American Heart Association (AHA). Molly McVoy receives partial salary support from the following research grants: Hartwell Foundation and NIH.

Declaration of interest

J Levin receives partial salary support from the following research grants: the National Institutes of Health (NIH) and the American Heart Association (AHA). M McVoy receives partial salary support from the following research grants: the Hartwell Foundation and the NIH. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

One referee declares research funding from Sunovion and is a speaker for Axsome, Intracellular, Janssen Pharmaceuticals, Lundbeck, Noven, Otsuka, and Teva Pharmaceuticals. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This work was supported in part by the Neurological and Behavioral Outcomes Center, University Hospitals Case Medical Center, Cleveland, Ohio.