Do Shared Decisions Up Medication Adherence in Schizophrenia?

Liam Davenport

June 20, 2017

COPENHAGEN, Denmark ― Involving hospitalized schizophrenia patients in treatment decisions improves patient satisfaction and confidence in treatment and may help improve ongoing adherence to medication regimens.

The study examined shared decision making (SDM), which encourages the full participation of patients in complex medical decisions. It revealed that the intervention significantly improved patient satisfaction and confidence both at discharge and at 12-month follow-up.

Moreover, the results showed that patient insight at discharge was significantly associated with adherence at 12 months, although SDM did not have a significant impact on objective outcomes or on polytherapy rates in comparison with treatment as usual.

The findings were presented here at the 13th World Congress of Biological Psychiatry.

New Concept in Psychiatry

The study was led by José María Villagrán Moreno, MD, PhD, Clinical Management Unit of Mental Health of the Hospital of Jerez de la Frontera, Cádiz, Spain. The investigators note that the findings show that SDM "favors better communication and confidence in the decision process of taking antipsychotics after being discharged." However, they acknowledge that further studies, with longer follow-up periods, are required to show that the results translate into measurable outcomes.

Although there has been growing interest in the use of SDM in patients with diabetes, cancer, and cardiac disease, its use is less common in patients with severe psychiatric disorders, despite the fact that the vast majority of patients are able to understand treatment choices and make rational decisions.

Building on previous research, the researchers conducted a prospective, randomized controlled trial of patients hospitalized with schizophrenia or schizoaffective disorder to examine the effectiveness of SDM in the choice of antidepressant medication at discharge.

Patients were randomly assigned to receieve either SDM or treatment as usual. SDM was administered 35 days prior to discharge. It consisted of three informative sessions that explored patient preferences, treatment options, and the development of a personal decision plan. These were followed by two deliberative sessions that focused on the plan and on reaching a consensual decision.

The current analyses include data on the first 72 of the planned 120 patients to complete the 12-month follow-up, of whom 35 were assigned to SDM and 37 to treatment as usual.

The average age of the patients was 44 years, and 76.4% were men. The majority (90.3%) of patients were not living alone, and 90.3% were deemed to have legal competency.

Of the patients, 69.4% had been diagnosed with schizophrenia, and the remaining 30.6% had been diagnosed with schizoaffective disorder. The mean duration of illness was 17.4 years, and the mean number of previous hospital admissions was six.

At baseline, the only difference between the group that received SDM and the group that received treatment as usual was that the patients in the SDM group had significantly higher scores on the total Positive and Negative Syndrome Scale (PANSS) compared with the patients who received treatment as usual, at 107.5 vs 102.7 (P = .043).

In the first study, the researchers focused on outcomes related to adherence, patient satisfaction, and readmission. Patients were assessed at baseline, at discharge, and at 3-, 6-, and 12-month follow-up.

SDM was associated with significant improvements over baseline on the Combined Outcome Measure for Risk Communication and Treatment Decision-Making Effectiveness at discharge compared with treatment as usual, at scores of 43.5 vs 31.6 on the satisfaction with communication subscale (P = .000) and 43.7 vs 34.1 on the confidence in decision subscale (P = .000).

On the satisfaction with communication subscale, these significant differences were maintained at 12 months, at 44.5 for SDM and 36.1 for treatment as usual (P = .000). On the confidence in decision subscale, the differences were 43.6 and 38.0, respectively (P = .012).

Interestingly, the significant difference in total PANSS scores at baseline had disappeared by discharge and remained nonsignificant for the rest of follow-up.

SDM was associated with improvements in the Brief Adherence Rating Scale (BARS) and days of hospitalization at 12 months compared with treatment as usual, although the differences did not reach statistical significance.

There was a significant decrease in losses to follow-up in the SDM group compared with the group that received treatment as usual, at one vs nine (P = .014).

Logistic regression analysis suggested that treatment adherence at 12 months, defined as a BARS score >71%, was significantly associated with, among other factors, insight at discharge, at a t value of -2.2 (P = .032).

In the second study, the team investigated the patients' use of antipsychotic medications. They found that at discharge, rates of antipsychotic polytherapy decreased across the whole cohort compared with baseline, from 44% to 41.7% (P = .003). This continued to the 12-month follow-up, at which the rate fell to 36.9% (P = .009).

There was a marked decrease in the number of patients taking more than two antipsychotic drugs. The average number of drugs taken per patient fell from four at baseline to two at the 12-month follow-up.

However, there were no significant differences in terms of the reductions in antipsychotic polytherapy or the mean number of antipsychotics taken between the group that received SDM and the group that received treatment as usual.

Dr Villagrán Moreno told Medscape Medical News that polytherapy is about more than just the patient.

"Sometimes, we think of polytherapy as a marker of nonresponsiveness, but at the same time, there is another side to the question," he said.

He described polytherapy as a measure of the prescriber's attitude toward use of more than one antipsychotic to treat schizophrenia. He noted that polytherapy "has more to do with the prescriber than with the patient, and with this study, we're trying to show that when we get into shared decision making with patients, both the prescriber and the patient need less polytherapy."

Dr Villagrán Moreno also noted that, although they measured adherence objectively using BARS and found no significant difference, "we have to take into account that it is more complex for a patient to be compliant with two or three antipsychotics than to be compliant with one antipsychotic treatment."

He believes the reason they found no significant difference in the reduction in polytherapy between SDM and usual treatment in the study is that there was a change in overall attitude toward polytherapy among the prescribers in the study, irrespective of whether they were applying SDM or treatment as usual.

Nevertheless, Dr Villagrán Moreno anticipates that once they reach the recruitment target for the study, the significant differences seen in subjective measures in the current analysis may also be observed with the objective assessments, particularly because the follow-up will be extended to 18 months.

Devil's Advocate

Commenting on the findings, Ofer Agid, MD, who was chair of the poster session and is a clinician scientist and psychiatrist in the Schizophrenia Program at the Center for Addiction and Mental Health, Toronto, Canada, said that SDM "sounds very important, and it is very important.

"But here is the devil's advocate question: Why didn't it impact outcomes? Probably outcome is multifactorial, and there are many, many, many other factors involved. Moreover, patients were subjectively more happy or satisfied with their medications, but that didn't impact adherence," he added.

Dr Agin said that "one of the major problems in schizophrenia is adherence with the antipsychotic treatment, and this, hypothetically ― at least on face value ― should impact dramatically the level of adherence.

"I mean there is a huge difference if you force medications or come in a paternalistic way and apply your thoughts vs a shared decision model. So here is a question: Why didn't we see it in the results?"

The DECIDE study was funded by the Andalusian government. Dr Villagrán Moreno has been a consultant for, has received grants/research support and honoraria, and has been on the speakers/advisory board of Janssen-Cilag, Pfizer, Bristol Myers Otsuka, GlaxoSmithKline, AstraZeneca, Sanofi Aventis, Lilly, Novartis, Lundbeck, AB-Biotic, and Ferrer. No other significant financial relationships have been disclosed.

13th World Congress of Biological Psychiatry. Posters P-02-006 and P-02-007, presented June 19, 2017.

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