Variability of Erythrocyte and Serum Lithium Levels Correlates with Therapist Treatment Adherence Efforts and Maintenance Treatment Outcome

Abstract

This study investigated the relationship between psychotherapeutic interventions and pharmacologic measures of pharmacotherapy treatment adherence in patients with bipolar I disorder, as well as the relationshipIt is widely recognized that many people with bipolar disorder have difficulty adhering to prescribed medication (Goodwin and Jamison 1990;Cochran and Gitlin 1988;Cochran 1984;Jamison and Akiskal 1983). Estimates of lithium noncompliance range from 20% to 66% (Cochran and Gitlin 1988) in such patients. Psychotherapy is frequently employed as an adjunctive treatment strategy for bipolar disorder; however, it is not clear to what extent such intervention might enhance medication treatment adherence in this patient population. We hypothesized that therapists' efforts targeted at enhancing pharmacotherapy treatment adherence would be associated with physiologic measures of treatment adherence and clinical outcome. Therefore, we initiated a study aimed at evaluating the outcome of therapists' interventions directed toward pharmacotherapy treatment adherence, as reflected by both pharmacologic measures of treatment adherence and rates of episode recurrence. Written informed consent was obtained from all participants in the MTBD study apprising them of both the study description and of the possible use of the data for additional research. At the time this study was conducted, 155 patients had been entered into the MTBD protocol. Our initial eligibility criterion for inclusion in our study was that of having been in the maintenance phase of the MTBD study for at least 1 year. This led to a pool of 63 eligible patients. The resulting sample of patients was selected utilizing the following inclusion criteria: (1) three audiotaped, ratable sessions from the first 3 months of the preventative phase; (2) five blood level determinations [which we considered the minimum to estimate standard deviation (SD) with accuracy] within 8 months of beginning the preventative phase, three of which were required to be from the first 3 months in order to correspond with the time period of the selected audiotapes; (3) being treated with lithium; and (4) remaining clinically stable during the time period when all blood level data were collected. For patients who had recurrences, all data were collected prior to the time of recurrence. Reasons for tapes not being ratable included the following: occasionally malfunctioning equipment, taping errors by the clinicians, and lost or inaudible tapes. Of the original pool of 63 eligible patients, six could not be included based on criterion 1; 17 could not be included based on criterion 2; one could not be included based on criterion 3; and eight could not be included based on criterion 4. Outcome was categorized as either recurrence or completion of 2 years maintenance without recurrence. One additional patient who dropped out of the MTBD study before a categorizable outcome could be determined was excluded. METHODSThirty patients were eligible for inclusion in this study. For 29 of these, we...

Role of treatment alliance in the clinical management of bipolar disorder: Stronger alliances prospectively predict fewer manic symptoms

“…Although treatment adherence was not directly measured in this study, it is possible that a strong alliance promoted greater acceptance of medication, which could partially explain the lower levels of mania over time. This interpretation dovetails with recent findings that serum lithium levels for patients with bipolar disorder increased when clinicians focused on collaborative relationship building, attitudes and acceptance of bipolar disorder, and the necessity of maintenance medications (Taylor et al, 2000). Thus, clinicians' efforts to openly address patients' treatment and illness-related attitudes and concerns may significantly improve adherence, and such discussions may be most productive in the context of trusting, collaborative doctor-patient relationship (Berk et al, 2004;Frank et al, 1995;Lewis, 2005).…”

Biological predictors of lithium response in bipolar disorder

“…32 Moreover, several groups attempted to predict the prophylactic effect of lithium in bipolar disorder by lithium ratio, although this is still controversial. There were several positive studies [33][34][35][36][37][38][39] as well as negative. [40][41][42][43] In addition, some researchers detected a possible relationship between lithium toxicity and RBC lithium concentration, 44,45 although this is also controversial.…”

Stress, social rhythms, and behavioral activation: Psychosocial factors and the bipolar illness course

“…Certainly, biologic factors, including non-adherence or discontinuation of pharmacologic treatment, contribute strongly to the onset of new episodes [28]. In fact, most studies have found that only 20% to 40% of episodes were preceded by a severe event.…”