Relationship of insight with medication adherence and the impact on outcomes in patients with schizophrenia and bipolar disorder: results from a 1-year European outpatient observational study

Abstract

BackgroundMany patients with schizophrenia and bipolar disorder have impaired insight and low medication adherence. The aim of this post hoc analysis was to explore the relationship between insight and medication adherence.MethodsWe included 903 patients with schizophrenia or bipolar disorder who participated in an observational study conducted in Europe on the outcomes of patients treated with two oral formulations of olanzapine over a 1-year period. Evaluations included Clinical Global Impression (CGI), Global Assessment of Functioning (GAF), insight (Scale to Assess Unawareness of Mental Disorder, SUMD) medication adherence (Medication Adherence Rating Scale, MARS), and therapeutic alliance (Working Alliance Inventory, WAI).ResultsMedication adherence was higher in bipolar patients (mean MARS score (SD) 6.5 (2.8) versus 5.8 (2.7) in schizophrenia; p < 0.001). Patients with schizophrenia had lower insight (i.e., SUMD item 1, unawareness of mental disorder, mean (SD) of 2.5 (1.3) in schizophrenia versus 1.9 (1.2) in bipolar, p < 0.001). Better insight was associated with higher adherence (Spearman Correlation Coefficient, SCC, ranging from 0.39 to 0.49 for the three SUMD general items, p < 0.0001 in all cases). Higher insight was related to a stronger therapeutic alliance (SCC ranging from 0.38 to 0.48, p < 0.0001). A path analysis revealed a positive impact of insight on adherence and alliance and that stronger alliance was related to lower clinical severity (lower CGI score).ConclusionInsight and adherence were found to be closely related. Insight impacts on the therapeutic alliance with mental health professionals. These factors are associated to treatment outcomes.

Why do psychiatric patients stop antipsychotic medication? A systematic review of reasons for nonadherence to medication in patients with serious mental illness

“…Measures of several dimensions of insight were shown to correlate with measures of attitude toward medication46 or therapeutic alliance;19 additionally, both insight and therapeutic alliance seem to predict the attitude toward medication,60 which indicates that these 3 variables are closely related. More detailed analyses that examined the relationship among these variables suggested that the effect of insight and therapeutic alliance on adherence is indirect and likely mediated by attitude toward medication 22,27,46.…”

“…A brief summary of results from each of the studies is provided in Tables 1 and 212,19–34 (prospective and post hoc analyses) and Tables 3 and 435–53 (cross-sectional). Most of the studies were conducted in patients with schizophrenia or schizophrenia-like disorders (75%, 27/36).…”

“…Another study in patients with schizophrenia reported that baseline scoring on a standardized insight scale56 differed significantly between adherent and nonadherent patients 33. Better insight reflected by scores in 3 insight domains was associated with improved adherence in patients with schizophrenia or bipolar disorder 19. In bipolar disorder, poor insight after acute mania treatment was associated with a greater probability of nonadherence during maintenance therapy 23.…”

“…Seven studies, 4 prospective and 3 cross-sectional, analyzed the association between therapeutic alliance and adherence. Physician-reported therapeutic alliance was strongly correlated with adherence at baseline, and improved therapeutic alliance was correlated with improved adherence after 1 year of follow-up based on a post hoc analysis of data from a prospective, observational study of patients with schizophrenia or bipolar disorder 19. In another prospective observational study, better patient-reported therapeutic alliance at baseline was associated with better adherence of patients with early-episode schizophrenia 6 months after hospital discharge 22.…”

Valued Living and Its Relationship to Medication Adherence in Patients with Bipolar and Comorbid Substance Use Disorders

“…It also would be useful to understand if the relationships observed among variables in the current sample are specific to bipolar disorder or are typical of various forms of psychopathology by including other psychiatric and non-psychiatric comparison groups. Furthermore, patients with mania can sometimes exhibit lower insight into their illness (Novick et al, 2015), and therefore the self-report nature of several of the measures should be considered, especially given the lack of associations identified with manic severity. In addition, there was low ethnic-minority representation in our sample and thus the utility of the VLQ in more diverse samples should continue to be examined.…”