Aim
This research programme aimed to investigate issues relating to the management of patient non-adherence with antipsychotic medication. The findings from the patient-related studies and the systematic literature review informed the development of a medication management staff training programme; which was evaluated in terms of the effects on mental health professionals’ understanding and clinical practice in Hong Kong. Background
Medication management interventions which are designed to maximise the potential benefits of antipsychotic medication for severe mental illness have shown promise in improving symptoms, reducing relapse rates and addressing non-adherence. Subsequent medication management studies which involve training mental health professionals in similar psychosocial interventions have also demonstrated that improvements in mental health professionals’ knowledge, attitudes and skills can result in improved patient outcomes; however, the studies have not been replicated outside western general psychiatry settings and therefore the effects of training mental health professionals in other clinical contexts have not been established. Methods
This research programme consists of a series of five studies that utilised a variety of methodological approaches. Three cross-sectional surveys were used to identify and explore clinical problems central to medication management in order to refine the staff training programme; the first investigates the extent of, and associations with, antipsychotic medication non-adherence in prisons. Qualitative interview data from the prison study provides additional context to the requirements for medication management training interventions by exploring prisoners’ experiences of taking antipsychotic medication. The second survey ascertains and explores the problem of non-adherence with antipsychotics in an Asian population, and the third provides an estimate of potential treatment-related physical health problems. A systematic literature review investigates studies which measure the effects of medication management training on clinicians’ knowledge, attitudes and skills. Finally concept mapping and clinicians’ narratives are used in a longitudinal case series 2 study in order to establish the transferability of medication management training to an Asian setting and evaluate the effects of training on clinicians’ understanding and clinical practice. Results
Patients’ positive attitudes towards antipsychotic medication, particularly awareness of the need for treatment predicted higher levels of adherence, and concerns about the adverse effects of these medications are closely related to the environmental context of treatment. Concerns associated with antipsychotic side effects appear to be less prominent when patients are not working or in prison but they may influence adherence when demands on functioning change. The modified medication management training was effective in improving clinicians’ understanding and was felt to be transferrable to an Asian setting, but patients’ and families’ traditional cultural beliefs about mental illness and concerns about the effects of western medication on physical health were found to be particular challenges when implementing adherence interventions. Patients with severe mental illness in Hong Kong are twice as likely compared to the general population to have developed metabolic syndrome, consequently medication management interventions could require greater focus on the identification and management of physical health problems; which may help to address patient and family concerns about long-term treatment. The staff training programme requires psychopharmacology teaching, provision of clinical supervision and side effects management content in order to improve clinicians’ confidence when implementing medication management interventions. Conclusions
Concerns about the adverse effects of treatment that influence adherence are environmentally bound. As influences on medication adherence are different in different settings, staff training programmes should place more emphasis on the local context in order to improve efficacy and the feasibility of implementation. The results suggest that in Hong Kong medication management interventions should have an increased focus on families and that treatment satisfaction could be a suitable target for interventions. The findings also present a question about whether previous medication management studies have given due consideration to predicting and managing concerns about the impact of side effects on functioning over the longer term and the potential effects of medication on patients’ physical well-being. The outcomes of this programme also demonstrate that future medication management training studies need to use robust study designs in order to more certainly attribute clinicians’ improvements to the training intervention and could consider measuring treatment satisfaction as a primary patient outcome measure. |