Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Health Services Research Department, Institute of Psychiatry, London, UK
Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Italy
Correspondence: Dr Corrado Barbui, Department of Medicine and Public Health, Section of Psychiatry, University of Verona, Ospedale Policlinico, 37134 Verona, Italy. Tel: +39 045 8074441; fax: +39 045 585871; e-mail: corrado.barbui{at}univr.it
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ABSTRACT |
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Aims To systematically review whether there are effective clinical interventions that community psychiatric services can implement to reduce non-adherence.
Method Systematic review and meta-regression analysis of randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were used to assess the efficacy of interventions to enhance adherence.
Results We reviewed 24 studies, more than half of which were RCTs. In 14 studies the experimental intervention was an educational programme. Five studies evaluated pre-discharge educational sessions, three studies explored the benefit of psychotherapeutic interventions and two studies looked at the effect of telephone prompts. The overall estimate of the efficacy of these interventions produced an odds ratio of 2.59 (95% CI 2.213.03) for dichotomous outcomes, and a standardised mean difference of 0.36 (95% CI 0.060.66) for continuous outcomes.
Conclusions Community psychiatric services can potentially use effective clinical interventions, backed by scientific evidence, for reducing patient non-adherence.
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INTRODUCTION |
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Several randomised controlled trials (RCTs) and controlled clinical trials (CCTs) have been conducted to assess the efficacy of a wide range of clinical interventions to reduce non-adherence in patients with psychosis (Chen, 1991). The focus of most of these studies has been the reduction of non-adherence to psychotropic medication or to scheduled appointments. Zygmunt and colleagues, who systematically reviewed RCTs and CCTs assessing psychosocial interventions for improving medication adherence in schizophrenia, showed that only a third of included studies reported significant treatment effects (Zygmunt et al, 2002). However, this review did not employ meta-analytic techniques, excluded studies assessing interventions for improving adherence to scheduled appointments and included highly selected populations of patients with schizophrenia. In this systematic review we adopted meta-analytic techniques to establish whether there are effective clinical interventions that community psychiatric services can implement to reduce medication and appointment non-adherence in patients with psychosis.
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METHOD |
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Search strategy
Relevant studies were located by searching Medline and PsycINFO from
January 1980 onwards. The following keywords were used: ADHERENCE or
COMPLIANCE or DROPOUT or ATTENDANCE or CONCORDANCE
or TERMINATION or CONTINUITY and SCHIZOPHRENIA
or PSYCHOSIS. Reference lists of relevant papers and previous
systematic reviews were hand-searched for published reports and citations of
unpublished research.
Data extraction
An ad hoc data extraction form was developed. Two reviewers
independently extracted the following information: country in which the study
was conducted, study setting, design, length of follow-up, main patient
characteristics, description of experimental and control intervention, and
definition of non-adherence. Definitions were grouped into two categories:
Several methods have been reported to establish adherence; these were grouped into four categories:
Clinical interventions for improving patient adherence were grouped into the following categories:
From each study the number of patients assigned to the experimental and control group was extracted, as was the number of patients meeting each studys definition of non-adherence. When appropriate, if only percentages were reported, they were converted into absolute numbers. For continuous outcomes the mean scores on any rating scale assessing non-adherence and the number of patients included in this analysis were recorded. Mean scores were recorded with the standard deviation (s.d.) or standard error (s.e.) of these values. When only the s.e. was reported, it was converted into s.d. using the method described by Altman & Bland (1996).
Statistical analysis
Dichotomous outcomes were summarised by calculating a Peto odds ratio (OR)
for each study, together with the 95% confidence interval (CI). An overall
weighted OR was then calculated as a summary measure. Continuous outcomes were
analysed by calculating a standardised mean difference (SMD) for each study.
This measure gives the effect size of an intervention in units of standard
deviation so that scores from different outcome scales can be combined into an
overall estimate of effect. A random effects model, which takes into
consideration any between-study variation, was adopted to combine the effect
sizes. Heterogeneity of treatment effect between studies was formally tested
using the 2 statistic. A meta-regression technique was in
addition adopted to examine the extent to which study-level covariates
predicted treatment effect.
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RESULTS |
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Characteristics of included studies
The majority of included studies were conducted in North America, four in
Europe, four in China and one in Egypt
(Table 1). A random allocation
design was adopted in 58% of studies, whereas the others adopted a CCT design.
The length of follow-up ranged from 2 weeks to 72 weeks, with a median of 24
weeks; this figure, however, did not include studies assessing non-adherence
to after-care programmes, since the length of follow-up in these reports
varied for each included patient depending on the length of time between
hospital discharge and the scheduled appointment
(Table 1). The mean number of
patients per study was 149 (s.d. 159.3, median 81.5, range 21660). Most
studies were performed in out-patient settings, 38% followed patients from
hospital to community and only a minority were conducted in hospital.
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In 14 studies the experimental intervention was an educational programme, in five cases specifically developed for family members. Five studies evaluated specific service policies, such as pre-discharge contacts between patients and the community team, or pre-discharge educational sessions about antipsychotic medication. Three studies assessed the benefit of psychotherapeutic interventions, in two cases adopting a cognitive approach and in one case a psychodynamic approach. Two studies assessed the effect of prompts in the form of telephone calls. Usual care was the control intervention in 63% of studies; in the others a non-specific intervention, similar to the experimental programme in terms of number of sessions, was employed. These interventions were developed to reduce non-adherence to psychotropic medication in 14 studies, assess attendance at first appointments after hospital discharge in six studies and increase attendance at scheduled appointments in four studies (Table 1).
Outcome of studies
Of the 24 included studies, 19 reported dichotomous and 5 continuous
outcome data. In 4 studies dichotomous outcome data were inferred from
percentages reported in the study tables. The treatment effect of each study
is presented in Figs 1 and
2. Overall, clinical
interventions for reducing patient non-adherence were significantly more
effective than control interventions. The pooled OR for dichotomous outcomes
was 2.59 (95% CI 2.213.03; Fig.
1); similarly, the pooled SMD for continuous outcomes was 0.36
(95% CI 0.060.66; Fig.
2). The funnel plot for studies with dichotomous outcome was not
symmetrical, indicating that publication bias could not be ruled out
(Fig. 3).
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Subgroup analysis
A subgroup analysis was carried out by stratifying the 19 studies with
dichotomous outcome data by the study characteristics reported in
Table 2. Studies adopting an
RCT design yielded an OR similar to studies adopting a CCT design. The effect
of clinical interventions for reducing non-adherence was greater in studies
with a short follow-up period (OR 2.27, 95% CI 1.782.90) than in those
with a follow-up of 6 months or more (OR 1.70, 95% CI 1.042.78);
moreover, it was slightly greater in studies enrolling homogeneous populations
of patients with schizophrenia, and in studies assessing adherence with
hospital discharge programmes (Table
2). Studies assessing adherence to medication yielded a slightly
higher OR than studies assessing adherence to out-patient and post-discharge
appointments. All five categories of clinical interventions were more
effective than control interventions in reducing patient non-adherence.
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Meta-regression analysis
The individual contribution of each of the above-mentioned study
characteristics to treatment outcome was assessed by a meta-regression
analysis (Table 3). Only two
covariates were significantly associated with treatment outcome, namely length
of follow-up and diagnosis. Length of follow-up was significantly associated
with a less favourable treatment outcome, whereas diagnosis of schizophrenia
was associated with a more favourable treatment effect.
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DISCUSSION |
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In contrast with this meta-analysis, the review by Zygmunt et al (2002) showed that only a third of 39 identified studies reported significant intervention effects. However, that review included only studies assessing the effect of interventions for reducing medication non-adherence. In our review, studies assessing the effect of interventions for improving adherence to scheduled appointments were included. Zygmunt et al (2002) included only studies of highly selected populations of people with schizophrenia, whereas we included non-selected populations of patients with psychosis. In addition, only studies in which adherence was one of the primary outcome measures were included in our analysis, whereas Zygmunt et al (2002) included studies in which adherence was not one of the primary end-points. These differences may explain their negative conclusions, as suggested by the evidence that studies where adherence was the central goal of the study provided positive results (Zygmunt et al, 2002). In some cases (for example, studies focusing on interventions not specifically developed for improving adherence), the decision whether adherence was one of the primary outcome measures or an ancillary variable was somewhat arbitrary. However, in most cases study authors clearly stated that the intervention was tested with the central goal of improving adherence (Bush et al, 1990; Xiang et al, 1994; Ran & Xiang, 1995; Dixon et al, 1997). We included only studies with a control group of patients receiving usual care, but Zygmunt et al (2002) did not exclude direct comparisons of different active strategies for improving medication adherence, such as behavioural management v. intensive case management, or psychoeducation plus family therapy v. psychoeducation plus relatives groups; in only some of these direct comparisons was there a control group receiving standard care. Finally, the meta-analytic technique we employed to re-analyse outcome data systematically excluded studies without data suitable for re-analysis. Taken together, these differences may have overemphasised the treatment effect found in our analysis and explain the negative conclusions reached by Zygmunt et al (2002).
Long-term effect of interventions for reducing non-adherence
A second issue, relevant from a clinical viewpoint, is the long-term
benefit of these interventions. Most of the included studies showed a positive
effect soon after the implementation of the intervention for reducing
non-adherence, but only a minority assessed whether the effect was maintained
in the long term. In the meta-regression model, length of follow-up was
negatively associated with treatment effect, suggesting that the benefit of
the interventions is less evident with increasing length of follow-up. Until
long-term data become available and until studies establish which intervention
maintains its effect in the long term, clinical interventions should be
implemented in practice as short-term measures. For example, orientation and
education about treatment and medications is essential to keep patients in
treatment, but this intervention should be frequently and routinely repeated
in the same patients, because it is unknown whether its effect is maintained
in the long term. Similarly, pre-discharge contacts between patients and the
out-patient team, or pre-discharge psychotherapeutic interventions, must
become a routinely delivered service policy, offered each time patients are
scheduled for discharge, even for patients who have already received it during
previous admissions. In some community psychiatric services this goal is
achieved by mixing in-patient and out-patient staff, so that in-patients are
treated by the same team who will eventually offer out-patient care. This
policy, which allows pre-discharge patientstaff contacts and the
implementation of therapeutic plans before hospital discharge, has been shown
to be associated with high rates of patient adherence in the long term
(Sytema et al,
1997).
Diagnostic issues
A third issue is that patients with psychosis are a rather heterogeneous
group. In many studies this diagnosis was adopted to collect representative
samples of patients seen in everyday practice, including not only those with
schizophrenia and related disorders, but also those showing psychotic features
requiring the use of antipsychotic drugs. In some cases ambiguous diagnostic
definitions were adopted, leading to the inclusion of patients with
schizophrenia and with other unspecified diagnostic characteristics. It is
possible that inclusion of these patients has increased the generalisability
of study findings, since in everyday conditions many typical patients do not
precisely fulfil diagnostic criteria of schizophrenia. Rather than relying on
diagnostic criteria only, therefore, it might be useful to include in studies
patients who are clinically or epidemiologically representative
(Thornicroft & Tansella,
2002). These patients need to be characterised using valid and
reliable descriptors, and in most studies this description is currently
lacking.
It is possible that interventions suitable for those with schizophrenia might not be suitable for other patients. In the meta-regression model we found that studies enrolling only homogeneous samples of people with schizophrenia were associated with a more favourable treatment effect, suggesting that these interventions are less effective in patients with other diagnoses. Similar findings emerged for other patient populations. Pampallona et al (2002), who performed a systematic review of patient adherence in the treatment of depression, showed that studies on adherence did not provide either reliable or consistent indications as to the efficacy of specific interventions. It is possible that psychoeducational or cognitive interventions, developed for patients with schizophrenia and for family members of those with schizophrenia, are not easily transferred to other categories of patients and family members with the same positive results.
Adherence to medication v. adherence to scheduled
appointments
The magnitude of effect of interventions developed for improving adherence
to medication was similar to that of interventions developed for improving
adherence to scheduled appointments. We acknowledge the difficulty of making a
clear distinction between these two categories, which were in many cases
ambiguous and somewhat artificial. Patients not wishing to take the prescribed
medicines might miss the scheduled appointments. Similarly, patients who want
to discontinue the contact with the community psychiatric service might also
stop taking the prescribed medicines. It might therefore be speculated that
failing to adhere to treatment programmes is a patient characteristic that
might result either in dropping out of treatment or in discontinuing the
medicines, or both. There is nothing in the literature to show that there are
two distinct categories of non-adherent patients, according to the definition
of non-adherence. In other words, the concept of non-adherence might be
unified and considered as one patient-related variable which can be measured
and defined in many different ways.
Studies published before 1980
A limitation of this analysis is the exclusion of study reports published
before 1980. This exclusion criterion was imposed for the purpose of
generating evidence easily applicable to the modern organisation of community
psychiatric services. Most studies before 1980 recruited patients resident in
psychiatric hospitals and assessed strategies for reducing non-adherence to
in-patient treatment regimens, or assessed compliance with out-patient
programmes implemented in a hospital-based context of care where community
facilities were lacking (Cramer &
Rosenheck, 1998). In contrast, after 1980 many countries developed
community-oriented systems of psychiatric care, with a diminished emphasis on
psychiatric hospitals and a high priority given to out-patient care delivered
by community mental health centres (Mosher
& Burti, 1994). Continuity of care has thus become a basic
quality requirement, essential to follow patients in their own context of life
for a long time. We acknowledge that in our approach we might have missed some
studies conducted in a community-oriented setting before 1980; however, this
choice allowed us to pool data derived from a group of psychiatric services
with a homogeneous commitment and a common mission. The exclusion of studies
assessing adherence at initial appointments was based on similar reasoning:
these constituted a separate group of studies, in which the main issue was not
keeping contacts in the long term, but developing strategies for better
psychiatric referral (Kluger & Karras,
1983).
Studies excluded from the meta-analysis
A second limitation is the exclusion of 23 studies because of the lack of
information suitable for re-analysis. This represents a well-known source of
potential bias when a quantitative approach is used in systematic reviews. The
funnel plot of included studies was not symmetrical, suggesting that some
studies might have been missed, for example small, negative studies
(Fig. 3). These studies might
be those not reporting absolute numbers or, possibly, those published in
non-English-language journals. Their exclusion might have overemphasised the
overall effect. To decrease this possibility two approaches were adopted.
First, we always attempted to infer absolute numbers from percentages reported
in study tables; this was only feasible with a high degree of confidence in
four cases, since in the others reviewers did not reach an agreement on the
exact numbers to extract. Second, excluded studies were compared with the
included ones and information on each study outcome was qualitatively
extracted in agreement with what was reported by the study authors. The
evidence that the proportion of reports with positive findings was similar in
the two groups of studies did not corroborate (although not completely
excluding) the possibility of selection bias.
Definition of adherence
Studies adopting different definitions of non-adherence and different
methods of assessing non-adherence were grouped together. These differences
are explained by the characteristics of the interventions under scrutiny: for
example, studies evaluating prompts in the form of telephone calls adopted
operational definitions of non-adherence such as non-attendance at
appointments, whereas studies evaluating educational strategies on medications
and side-effects measured the proportion of patients taking psychotropic drugs
as prescribed. In some cases, however, the same interventions were evaluated
using different definitions, for example studies assessing adherence after
hospital discharge adopted definitions such as attendance at first out-patient
appointment, attendance at five out-patient appointments, or attendance at a
predefined proportion of appointments during follow-up. Only in a minority of
studies were rating scales employed. These differences represent study
limitations that might have been responsible for some between-study
heterogeneity observed in the meta-analysis. The meta-regression model could
have investigated this potential source of heterogeneity, but this approach
was not used because it would have inevitably decreased the power of the
analysis, generating findings of uncertain clinical relevance.
Recommendations
Much is still to be done in the field of treatment adherence in patients
with schizophrenia and severe mental disorders. Experimental studies have to
address the effectiveness of educational strategies, psychotherapeutic
programmes and specific service policies in large samples of patients
recruited in many different settings and followed in the long term. Patients
with schizophrenia should be considered separately from those with other
diagnoses. Trials must adopt a high standard in terms of conduct and
reporting: exclusion rates and reasons for exclusion should always be
reported, as well as the proportion of patients failing to adhere to treatment
at the end of the acute phase and the proportion of patients remaining
adherent at follow-up. Absolute numbers should be given, avoiding the use of
percentages without reporting the denominator to which they refer. Outcome
data have to be reported for both completer and intention-to-treat
samples.
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Clinical Implications and Limitations |
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LIMITATIONS
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APPENDIX 1: Potentially relevant studies identified by the electronic search and subsequently excluded from the meta-analysis |
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Battle, E. H., Halliburton, A. & Wallston, K. A. (1982) Self medication among psychiatric patients and adherence after discharge. Journal of Psychosocial Nursing Mental Health Service, 20, 2128.
Blake, D. D., Owens, M. D. & Keane, T. M. (1990) Increasing group attendance on a psychiatric unit: an alternating treatments design comparison. Journal of Behavioural Therapy and Experimental Psychiatry, 21, 1520.[CrossRef][Medline]
Boczkowski, J. A., Zeichner, A. & DeSanto, N. (1985) Neuroleptic compliance among schizophrenic outpatients: an intervention outcome report. Journal of Consulting and Clinical Psychology, 53, 666671.[CrossRef][Medline]
Bogin, D. L., Anish, S. S., Taub, H. A., et al (1984) The effects of a referral co-ordinator on compliance with psychiatric discharge plans. Hospital and Community Psychiatry, 35, 702706.[Medline]
Bond, G. R., Miller, L. D., Krumwied, R. D., et al (1988) Assertive case management in three CMHCs: a controlled study. Hospital and Community Psychiatry, 39, 411418.[Medline]
Brown, C. S., Wright, R. G. & Christensen, D. B. (1987) Association between type of medication instruction and patient knowledge, side effects and compliance. Hospital and Community Psychiatry, 38, 5560.[Medline]
Bush, C. T., Langford, M. W., Rosen, P., et al (1990) Operation outreach: intensive case management for severely psychiatrically disabled adults. Hospital and Community Psychiatry, 41, 647649.[Medline]
Cassino, T., Spellman, N., Heiman, J., et al (1987) Invitation to compliance: the prolixin brunch. Journal of Psychosocial Nursing, 25, 1519.
Cruz, M., Cruz, R. F. & McEldoon, W. (2001)
Best practice for managing noncompliance with psychiatric appointments in
community-based care. Psychiatric Services,
52,
14431445.
Dixon, L., Weiden, P., Torres, M., et al (1997) Assertive community treatment and medication compliance in the homeless mentally ill. American Journal of Psychiatry, 154, 13021304.[Abstract]
Eckman, T. A., Liberman, R. P., Phipps, C. C., et al (1990) Teaching medication management skills to schizophrenic patients. Journal of Clinical Psychopharmacology, 10, 3338.[Medline]
Guimon, J. (1995) The use of group programs to improve medication compliance in patients with chronic diseases. Patient Education and Counseling, 26, 189193.[CrossRef][Medline]
Hornung, W. P., Kieserg, A., Feldmann, R., et al (1996) Psychoeducational training for schizophrenic patients: background, procedure and empirical findings. Patient Education and Counseling, 29, 257268.[CrossRef][Medline]
Larsen, D. L., Nguyen, T. D., Green, R. S., et al (1983) Enhancing the utilisation of outpatient mental health services. Community Mental Health Journal, 19, 305320.[Medline]
Lowe, R. H. (1983) Responding to no shows: some effects of follow up method on community mental health centre attendance patterns. Journal of Consulting and Clinical Psychology, 50, 602603.[CrossRef]
Macpherson, R., Jerrom, B. & Hughes, A. (1996) A controlled study of education about drug treatment in schizophrenia. British Journal of Psychiatry, 168, 709717.[Abstract]
Merinder, L. B., Viuff, A. G., Laugesen, H. D., et al (1999) Patient and relative education in community psychiatry: a randomised controlled trial regarding its effectiveness. Social Psychiatry and Psychiatric Epidemiology, 34, 287294.[CrossRef][Medline]
ODonnell, M., Parker, G., Proberts, M., et al (1999) A study of client-focused case management and consumer advocacy: the Community and Consumer Service Project. Australian and New Zealand Journal of Psychiatry, 33, 684693.[CrossRef][Medline]
Phan, T. (1995) Enhancing client adherence to psychotropic medication regimens: a psychosocial nursing approach. International Journal of Psychiatric Nursing Research, 2, 147172.
Solomon, P., Draine, J. & Mannion, E. (1996) The impact of individualised consultation and group workshop family education interventions in ill relative outcomes. Journal of Nervous and Mental Disease, 184, 252255.[CrossRef][Medline]
Streicker, S. K., Amdur, M. & Dincin, J. (1986) Educating patients about psychiatric medications: failure to enhance compliance. Psychosocial Rehabilitation Journal, 4, 1528.
Trautman, R. & Reagan, J. T. (1983) How to increase revenues through appointment reminders. Hospital Topics, 33, 34.
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APPENDIX 2: Randomised controlled trials and controlled clinical trials included in the meta-analysis |
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Chaplin, R. & Kent, A. (1998) Informing patients about tardive dyskinesia. Controlled trial of patient education. British Journal of Psychiatry, 172, 7881.[Abstract]
Cramer, J. A. & Rosenheck, R. (1999) Enhancing medication compliance for people with serious mental illness. Journal of Nervous and Mental Disease, 187, 5355.[CrossRef][Medline]
Glick, I. D., Fleming, L., DeChillo, N., et al (1986) A controlled study of transitional day care for non-chronically-ill patients. American Journal of Psychiatry, 143, 15511556.[Abstract]
Gomez Carrion, P. G., Swann, A., Kellert Cecil, H., et al (1993) Compliance with clinic attendance by outpatients with schizophrenia. Hospital and Community Psychiatry, 44, 764767.[Medline]
Hayward, P., Chan, N., David, A., et al (1995) Medication self-management: a preliminary report on an intervention to improve medication compliance. Journal of Mental Health, 4, 511517.[CrossRef]
Hornung, W. P., Klingberg, S., Feldmann, R., et al (1998) Collaboration with drug treatment by schizophrenic patients with and without psychoeducational training: results of a 1-year follow-up. Acta Psychiatrica Scandinavica, 97, 213219.[Medline]
Kelly, G. R. & Scott, J. E. (1990) Medication compliance and health education among out patients with chronic mental disorders. Medical Care, 28, 11811197.[Medline]
Kemp, R., Hayward, P., Applewhaite, G., et al
(1996) Compliance therapy in psychotic patients: randomised
controlled trial. BMJ,
312,
345349.
Kopelowicz, A., Wallace, C. J. & Zarate, R.
(1998) Teaching psychiatric inpatients to re-enter the
community: a brief method of improving the continuity of care.
Psychiatric Services,
49,
13131316.
Masnik, R., Olarte, S.W. & Rosen, A. (1981) Using a PRN list to see appointment-breakers on a walk in basis. Hospital and Community Psychiatry, 32, 635637.[Medline]
Olfson, M., Mechanic, D., Boyer, C. A., et al
(1998) Linking inpatients with schizophrenia to outpatient
care. Psychiatric Services,
49,
911917.
Ran, M. & Xiang, M. (1995) A study of schizophrenic patients treatment compliance in a rural community. Journal of Mental Health, 4, 8589.[CrossRef]
Robinson, G. L., Gilbertson, A. D. & Littwack, L. (1986) The effects of a psychiatric patient education to medication program on postdischarge compliance. Psychiatry Quarterly, 58, 113118.
Seltzer, A., Roncari, I. & Garfinkel, P. (1980) Effect of patient education on medication compliance. Canadian Journal of Psychiatry, 25, 638645.[Medline]
Sharma, S. B., Elkins, D., van Sickle, A., et al (1995) Effect of predischarge interventions on aftercare attendance process and outcome. Health and Social Work, 20, 1520.
Shivack, I. M. & Sullivan, C. W. (1989) Use of telephone prompts at an inner-city outpatient clinic. Hospital and Community Psychiatry, 40, 851853.[Medline]
Sledge, W. H., Moras, K., Hartley, D., et al (1990) Effect of time-limited psychotherapy on patient dropout rates. American Journal of Psychiatry, 147, 13411347.[Abstract]
Stickney, S. K., Hall, R. C. W. & Gardner, E. R. (1980) The effects of referral procedures on aftercare compliance. Hospital and Community Psychiatry, 31, 567569.[Medline]
Strang, J. S., Falloon, I. R., Moss, H. B., et al (1981) The effects of family therapy on treatment compliance in schizophrenia. Psychopharmacological Bulletin, 17, 8788.[Medline]
Xiang, M., Ran, M. & Li, S. (1994) A controlled evaluation of psychoeducational family intervention in a rural Chinese community. British Journal of Psychiatry, 165, 544548.[Abstract]
Xiong, W., Phillips, M. R., Hu, X., et al (1994) Family-based intervention for schizophrenic patients in China. A randomised controlled trial. British Journal of Psychiatry, 165, 239247.[Abstract]
Youssef, F. A. (1984) Adherence to therapy in psychiatric patients: an empirical investigation. International Journal of Nursing Studies, 21, 5157.[Medline]
Zhang, M., Wang, M., Li, J., et al (1994) Randomised-control trial of family intervention for 78 first-episode male schizophrenic patients. An 18-month study in Suzhou, Jiangsu. British Journal of Psychiatry, 165 (suppl. 24), 96102.
Altman, D. G. & Bland, J. M. (1996)
Detecting skewness from summary information. BMJ,
313, 1200.
Breen, R. & Thornhill, J. T. (1998) Noncompliance with medication for psychiatric disorders. Reasons and remedies. CNS Drugs, 9, 457471.
Bush, C. T., Langford, M. W., Rosen, P., et al (1990) Operation outreach: intensive case management for severely psychiatrically disabled adults. Hospital and Community Psychiatry, 41, 647649.[Medline]
Chen, A. (1991) Noncompliance in community psychiatry: a review of clinical interventions. Hospital and Community Psychiatry, 42, 282287.[Medline]
Cramer, J. A. & Rosenheck, R. (1998)
Compliance with medication regimens for mental and physical disorders.
Psychiatric Services,
49,
196201.
Dixon, L., Weiden, P., Torres, M., et al (1997) Assertive community treatment and medication compliance in the homeless mentally ill. American Journal of Psychiatry, 154, 13021304.[Abstract]
Kluger, M. P. & Karras, A. (1983) Strategies for reducing missed initial appointments in a community mental health centre. Community Mental Health Journal, 19, 137143.[Medline]
Mosher, L. R. & Burti, L. (1994) Community Mental Health. New York: Norton.
Pampallona, S., Bollini, P., Tibaldi, G., et al
(2002) Patient adherence in the treatment of depression.
British Journal of Psychiatry,
180,
104109.
Ran, M. & Xiang, M. (1995) A study of schizophrenic patients treatment compliance in a rural community. Journal of Mental Health, 4, 8589.[CrossRef]
Sackett, D. L. & Haynes, B. R. (1976) Compliance with Therapeutic Regimens. Baltimore, MD: Johns Hopkins University Press.
Sytema, S., Micciolo, R. & Tansella, M. (1997) Continuity of care for patients with schizophrenia and related disorders: a comparative south-Verona and Groningen case-register study. Psychological Medicine, 27, 13551362.[CrossRef][Medline]
Thornicroft, G. & Tansella, M. (2002) Mental health services research. In Evidence in Mental Health Care (eds S. Priebe & M. Slade), pp. 81100. Hove: Brunner-Routledge.
Xiang, M., Ran, M. & Li, S. (1994) A controlled evaluation of psychoeducational family intervention in a rural Chinese community. British Journal of Psychiatry, 165, 544548.[Abstract]
Zygmunt, A., Olfson, M., Boyer, C. A., et al
(2002) Interventions to improve medication adherence in
schizophrenia. American Journal of Psychiatry,
159,
16531664.
Received for publication October 10, 2002. Revision received February 21, 2003. Accepted for publication April 16, 2003.