1. Effectiveness of adherence therapy in young people with psychosis Dr Martin Jones Associate Director of Nursing Simon Whitfield Chief Pharmacist

2. Overview

3. Stopping medication is the most powerful predictor of relapse 6 4.89 4.57 5 4 Hazard ratio 3 2 1 n=104 n=63 0 Second relapse First relapse Survival analysis of relapse using medication status as a time-dependent covariate risk The risk of a first or second relapse when not taking medication is ~5 times greater than when taking it Robinson et al. Arch Gen Psychiatry 1999;56:241–247

5. Mean number of days with ‘no therapy’ Continuous therapy ANY ‘no therapy’ days † 5.2% 7.1% 100 350 94.8% 92.9% 300 80 250 60 Patients (%) 200 Days 125.0 40 150 110.2 100 20 n=349 n=326 n=349 n=326 50 0 0 SGA FGA FGA SGA Adherence affects almost all patients* High percentages of patients receiving oral SGA and FGA treatment received no antipsychotic therapy for a substantial portion of study follow-up *Based on availability of medication in a 1-year naturalistic study; †’No therapy’ defined as days in which medication was not available. Patients were considered to be receiving therapy on days when medication was available and COULD have been taken Mahmoud et al. Clin Drug Invest 2004;24:275–286 FGA, first-generation antipsychotic; SGA, second-generation antipsychotic

6. To paraphrase: “An effective intervention to improve adherence is worthy of a Nobel Prize”

7. What do patients think about antipsychotic medication?

8. What do patients think about their medication? 26 patients Early psychosis Prescribed antipsychotic medication Most striking observation Patients had a mix of positive and negative views about antipsychotic medication Discrepant with the “Noise” Meek I. and Gray R. (in preparation)

10. “It is the companies and the research; I was dead against them when I was first taking it because of how it made me feel. I started to accumulate reasons not to take it. I raged against the drug companies and their propaganda, making themselves the best option…” [P10, Male, 30]

11. Theme: The drugs don’t work

12. “They keep people on these drugs for too long. I am no better than when I was not on them…” [P10, Female, 23]

13. “I get no effects from it. It does nothing to me. I don’t have a mental problem” [P4, Male, 27]Meek I. and Gray R. (in preparation)

15. “It doesn’t chill me out enough. It doesn’t quite relieve my symptoms” [P12, Male, 30]

16. “If doesn’t work as well as I hoped for. I still feel worried/paranoid and I still hear voices. I’m relying on something to help me get through, although feeling it was not necessary to take it” [P6, Male, 22]

17. “I wish my medication got rid of all my symptoms. My thoughts are less distressing but I still have them at times” [P20, Male, 27]Meek I. and Gray R. (in preparation)

19. “The effectiveness of and the speed of it working for me. It worked within two weeks, it continued to be effective. I would recommend it as an effective antipsychotic drug” [P17, male, 28]

20. “They are doing what they are supposed to do with some thoughts. They are doing what they are supposed to do. That is the main factor [P18, Male, 28]

21. “I’m not so jumpy. It has made things more manageable [P13, Female, 35]Meek I. and Gray R. (in preparation)

23. Some patients said that they experienced no side effects at all

24. “I have no bad reactions, no side effects” [P6, Male, 22]

25. “I haven’t experienced any side effects” [P16, Female, 27]

26. Sedation was the most frequently reported and most troubling side effect

27. “The first time after taking it I couldn’t get up for 12 hours. Now 2-4 hours after taking it I can ‘get up’, but I can’t get out of bed. It makes me dark under my eyes. It makes you feel weak for hours. I have somehow to get used to it” [Patient 1, Male, 23]

28. “If you move about a lot you don’t notice it. If you take down time the effects seem to snow ball and it gets on top of you. If you’re tired it makes you more tired. It’s like walking in water. You learn to fight the resistance” [Patient 2, Male, 30] Meek I. and Gray R. (in preparation)

30. Some patients said that they experienced no side effects at all

31. “I have no bad reactions, no side effects” [P6, Male, 22]

32. “I haven’t experienced any side effects” [P16, Female, 27]

33. Sedation was the most frequently reported and most troubling side effect

34. “The first time after taking it I couldn’t get up for 12 hours. Now 2-4 hours after taking it I can ‘get up’, but I can’t get out of bed. It makes me dark under my eyes. It makes you feel weak for hours. I have somehow to get used to it” [Patient 1, Male, 23]

35. “If you move about a lot you don’t notice it. If you take down time the effects seem to snow ball and it gets on top of you. If you’re tired it makes you more tired. It’s like walking in water. You learn to fight the resistance” [Patient 2, Male, 30] Meek I. and Gray R. (in preparation)

36. Why don’t patients take their medication?

38. Improving treatment adherence

39. Candidate interventions Patient education Financial incentives Depot (long acting injections) Adherence therapy Problem solving Ambivalence Beliefs

40. The knowledge fallacy…

42. What is adherence therapy? Collaborative approach Theory is that by giving people choice and allowing people to make meaningful decisions about their care and treatment means they will stick with their treatment for longer leading to healthier outcomes

43. Adherence therapy: theory

44. Adherence Therapy: key components Structured medication problem solving Looking back Exploring ambivalence Talking about beliefs and concerns Looking forward

45. Does adherence therapy work? Number of short term studies Small scale Highly motivated work force So what about the real world setting?

46. What we wanted to know? Is it acceptable to staff? Is it acceptable to patients? Does it make a difference?

47. From therapy to practice Study Design EIP Whole team Agree assessment measures (RAG system) Interviews Deliver intervention Psychopharmacology training Adherence therapy training (5-10 days) Looked at impact 12 months post training and compared with the 12 months prior to training

49. “Staff structure their time better”

50. “Work is more collaborative now”

51. “I have a much better understanding of how medicines work”

52. “AT ideas are used regularly in practice”

53. “Time is a barrier”

55. Adherence therapy training in early psychosis: effect on relapse rates P<.05 Mean number of relapses in past 12 months Jones M. Brown E. Gray R. (in prep) Design: Mirror image study (n=32) Endpoint: Relapse in previous 12 months

56. To paraphrase: “An effective intervention to improve adherence is worthy of a Nobel Prize”