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% DrugPlacebo

Davis & Andrukaitis 1986 J Clin Psychopharmacol

Adherence and Chronic Illness Stopping APS suddenly: 46% relapse in 6/12 if stable 56% in two years Stopping gradually: 50% over 2 years Viguera et al 1997

Robinson D et al, Arch Gen Psych, 1999

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 Arch Gen Psych

Insight and medication attitudes Day, J., et al Arch Gen Psych

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 Arch Gen Psych

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

PD SE NFM +ve correlation-ve correlation Well AIS DSH Hosp