Current Clinical Pharmacology - Volume 6, Issue 2, 2011

Although Hippocrates, almost 2500 years ago, recognized the difficulties of patient compliance when he wrote “Keep watch also on the faults of the patients, which often make them lie about the taking of things prescribed” [1], the topic continues to produce considerable controversy at present. Dictionaries tend to be slow assuming the evolution of language and incorporating new terms. However, in medicine it is essential the rapid incorporation of new terms or changing the existing ones in order to communicate new ideas, concepts and practices. Compliance, adherence and concordance are a clear example of this fact. At the present time, psychiatric disorders are a growing public health concern worldwide. By the year 2020, the proportion of the contribution of neuropsychiatric conditions to overall disability is expected to be about 20%, compared with only 9% in 1990 [2]. Although psychological treatments of proven efficacy are available for the management of the majority of psychiatric disorders, the most common form of treatment worldwide is the use of psychoactive medication. The appropriate prescription of medicines is a core element of the delivery of modern mental health with psychoactive drugs widely used not only to relieve symptoms and cure conditions but to prevent relapses in the future. Nevertheless, there is a considerable gap between best care, defined as the optimal use of proven efficacious pharmacotherapies in psychiatric disorders, and usual care, the actual level of efficacious care being provided to psychiatric patients. In particular, poor adherence to pharmacologic treatment of psychiatric disorders is a worldwide problem of striking magnitude that contributes to the gap care. Non-adherence prevents patients from gaining access to the best treatment, and this may be particularly problematic in psychiatric disorders. A number of rigorous reviews have found that, in developed countries, adherence among patients suffering chronic diseases averages only 50% [3-5]. The magnitude and impact of poor adherence in developing countries is assumed to be even higher given the paucity of health resources and inequities in access to health care [6]. The factor that appears to most strongly correlate with adherence is the patient's own beliefs influenced by personal knowledge and experience [7] as well as that of family and friends [8]. Understanding the patient perspective allows the provider to give treatment options congruent with patient needs and values [9]. A patient-centered approach is essential to promoting adherence and current levels of non-adherence imply a failure to address patients' needs and preferences and represent a fundamental inefficiency in the delivery and organization of the public health systems [10]. One of the most noticeable changes in health care over the last few decades has been the increased involvement of patients in their treatment decisions [11]. Health care has been evolving away from a "disease-centered model", where physicians make almost all treatment decisions based largely on clinical experience and data from various medical tests, and toward a "patientcentered model", where patients become active participants in their own care and receive services designed to focus on their individual needs and preferences, in addition to advice and counsel from health professionals. At the present time, patient-centered care is recognized as a measure of the quality of health care [11]. Studies relate that patient-centered care improves communication, promotes patient involvement in care, creates a positive relationship with the provider, and results in improved adherence to treatment plan [12, 13]. Indeed this has lead to replacement of the more authoritarian term ‘ compliance’ with that of ‘ concordance’ as a primary aim of the consultation. The latter term suggests a “ &hellip frank exchange of information, negotiation, and a spirit of cooperation” [14]. The articles included in this Current Clinical Pharmacology Special Issue are based on the best available evidence on compliance, adherence and concordance in medicine taking of psychiatric patients. This special issue contains highly significant papers arising from the experience and knowledge of professionals belonging to academic university field, health care system, research institutions, and government planning services. These papers will be of help to all mental healthcare professionals by providing guidance on how to involve patients in the decision to prescribe medicines and on how to support patients in their subsequent use of medicines. De las Cuevas, from the Pharmacoepidemiology and Drug Use Studies Research Group at the University of La Laguna in the Canary Islands, Spain, clarify in his paper the terminology used in relation to patients' medication-taking behavior: compliance, adherence and concordance bringing recommendations for the adequate use of terminology. Cabrera, from the Department of Psychiatry at the Queen's University in Kingston, Ontario, Canada, in an exquisite short piece, charts the contemporary history of the term “compliance” and its cognates, discusses the recently published guidelines concerning the assessment of adherence in patients with serious mental illnesses and stresses that improving the assessment of adherence and favoring its enhancement can generate interesting ethical quandaries that will be approached in the light of the relatively new emergent notion of “moral distress.”.....

Medical terminology is at continuous process of change since the language of medicine needs the rapid incorporation of new terms or changing the existing ones to be in touch with new ideas, concepts and practices. The evolution of the terms “compliance”, “adherence” and “concordance” in the field of medicine-taking represents a good example of this. Although these three terms are frequently used interchangeably generating some confusion, compliance, adherence and concordance mean different things and must be used in different ways. Compliance refers to the extent to which patients follow doctors' prescription about medicine taking; adherence refers to the extent to which patients follow through decisions about medicine taking; and concordance refers to the extent to which patients are successfully supported both in decision making partnerships about medicines and in their medicines taking. This terminology evolution may actually be more important than mere semantics since better adherence to a treatment regimen could be achieved through open-ended physician-patient communication, incorporating the beliefs and preferences of the patient in the decision-making process. At present time, concordance could be useful as a normative or aspirational term while compliance and adherence must be the terms used for scientific measurement in medicine-taking field.

This paper starts with an attempt to chart the contemporary history of the term “Compliance” and its cognates. It also discusses the recently published guidelines concerning the assessment of adherence in patients with serious mental illnesses, dedicating its middle part to comment on the research and clinical methods to assess adherence in patients. The current consensus amongst experts can be summarized, from a clinical point of view, in a simple rule of thumb: enhancing adherence should depend on simple interventions originating from a multidisciplinary perspective and should include patients' input. Despite its apparent simplicity, improving the assessment of adherence and favouring its enhancement can generate interesting ethical quandaries that will be approached in the light of the relatively new emergent notion of “moral distress”.

There is growing interest in shared decision-making (SDM) in which the provider and patient go through each phase of the decision-making process together, share treatment preferences, and reach an agreement on treatment choice. Although a majority of the research evaluating SDM has been conducted under “physical” health conditions, patients' participation and SDM for mental health conditions has received increasing interest since the mid-1990s. SDM in mental health care can be more complex than in general health care because that several patient characteristics, health care provider, and system level factors may hinder normalization and implementation of this model into clinical practice. To date, in comparison with other health problems, there are few studies which have assessed SDM in this context. In spite of that, evidence points favorably towards the inclusion of SDM in mental health treatment decisions, given that the majority of patients with mental illness prefer to be involved in the process and wish to have information. However, more studies are needed to provide evidence about the impact of SDM on treatment compliance and health care outcomes. In this overview, the authors present the current state and the future perspectives of SDM in mental health.

Treatment adherence is related to “self-regulation” of prescribed drugs. Patients organise their drug intake around their own priorities, which may be very different from prescribers' priorities, since most of the patients value their personal concerns and/or their social roles more than the benefits of a prescribed treatment. A gap exists between patients' and professionals' views. This gap is mainly related to patients' health beliefs and physicians' attitudes. A number of strategies can help professionals overcome gaps between their treatment options for depression and schizophrenia and the “real world” alternatives shared by the lay public, patients, their relatives, and political stakeholders. These strategies include integrated care and recovery, family engagement, and the development of a mutualistic patient/physician relationship with the adoption of advance directives and appropriate guidelines that incorporate the patient's choices. The effective implementation of these combined strategies within the person-centred care model empowers patients to collaborate with mental health professionals and their families in making complex health care choices. Barriers to this process include factors affecting the control, contact and communication facets of the patient/physician relationship.

Lack of adherence is a universal risk in medicine. Its consequences in terms of outcome, suffering and economic costs are immense. This is a selective review of the putative factors involved in medicine taking behavior. Adherence is multidetermined by a number of variables ranging from patient sociodemographic characteristics to factors related to patient/ psychiatrist interaction, drug tolerability and organization of care. A relevant piece of responsibility comes from the drug itself and the patient's subjective tolerability which together with the characteristics of long term treatment and insufficient insight and support result in poor or lack of adherence. The context of the patient/professional therapeutic alliance, the patient's capacities and health system availability are ultimately decisive.

This article presents a narrative review of qualitative research about reasons users consuming mood modifying drugs have to continue or discontinue medicine taking. Qualitative research provides insight to the phenomena of interest and has been used to understand how patients take medicines and identifies explicative models. Researchers have looked at how mood modifying drugs consumption fit in different models of medicine taking. Consumption of medicines involves frequently two sides from the point of view of the patients, the consideration of benefits and risk. Patients have to balance their perceptions and experiences of both sides and make decisions. It became clear that individual decisions composing the “personal career” of taking mood-modifier drugs is similar to other treatments of chronic conditions but with different limiting or adjuvant social forces at work. Mood modifying drugs produce not only concerns in relation to the drugs reactions but also to the perception that society has about them. Understanding the patient's perspective and the factors involved in the evaluation process for decision making about continuation or discontinuation of mood modifying drugs can help professionals to avoid longer than necessary consumption or early dropouts.

It was conducted a systematic review of economic evaluations that assessed the cost-effectiveness of interventions to enhance the medication adherence in psychiatric patients. Several bibliographic databases were searched: MEDLINE, MEDLINE in process, PSYCINFO, EMBASE, Cochrane Controlled Trials Register, CINAHL, CRD, EconLit, Science Citation Index and Social Science Citation Index. Full economic evaluations which assessed interventions to enhance the adherence to drug therapy in adult patients with a mental illness were included. Data were extracted and the methodological quality of selected studies was assessed. The information was synthesized through narrative procedures. Four clinical trials and two ongoing studies fulfilled the selection criteria. Two studies did not find significant differences in adherence between the interventions (a compliance-enhancing program, a therapeutic drug monitoring and a pharmacy-based intervention) and the control groups; one study found that a compliance program was more effective than a non-specific counselling intervention over 18 months in psychotic patients; another study found better results in terms of adherence among high-severity depressed patients receiving a stepped collaborative care during 12 months in comparison to a control group; in moderate-severity patients the differences disappeared after the first 6 months. None of the four studies found significant differences in costs between groups because of the low statistical power. In summary, adherence enhancing programs could be cost-effective in psychiatric patients although this statement is based on few studies with limited methodological quality. It is necessary more and better research on the costeffectiveness of interventions in the field of mental health.

Based on the material available in both the scientific literature and on the web, the present paper provides an updated pharmacological, chemical, toxicological and behavioural overview of Bromo-Dragonfly (1-(8-bromobenzo[1,2- b;4,5-b']difuran-4-yl)-2-aminopropane; ‘ B-fly’). B-Fly is a powerful, long lasting, LSD-like, hallucinogenic drug, which has been associated with a number of acute intoxications and fatalities in a number of countries. A critical discussion of the potential of misuse of B-fly but also of the methodological limitations, which are intrinsically associated with the analysis of online, non-peer reviewed, material, is presented. It is concluded that the availability of online information on novel psychoactive drugs, such as B-fly, may constitute a public health challenge. Better international collaboration levels may be needed to tackle this novel and fast growing phenomenon

Calcineurin inhibitors (CNI), a cornerstone of current immunosuppressive therapy, have important cardiovascular and oncogenic side effects and CNI nephrotoxicity contributes to the multifactorial process called “chronic allograft dysfunction”, the leading cause of chronic allograft failure among kidney transplant recipients. New drugs, with a different mechanism of action, are being developed focusing on a better balance between drug efficacy and toxicity. These novel compounds interfere with either T-cell mediated or antibody-mediated rejection. In this review, we report on the mechanism of action, pharmacokinetics and preliminary results of clinical trials of these promising new immunosuppressive drugs.

Suramin is a polysulfonated naphthylurea, which was originally synthesized and designed as a treatment for trypanosomiasis and selected malignancies and metastatic diseases. Increasing evidence indicates that suramin is also effective in interfering with many other pathophysiological processes in animal models. For example, suramin can enhance renal regeneration after ischemia/reperfusion injury, attenuate liver damage following CD95 stimulation and endotoxic shock, reduce brain injury induced by ischemia, and suppress myocardial inflammation. Further, suramin has an anti-fibrotic effect in liver and muscle. Mechanistic studies show that suramin inhibits apoptosis, suppresses expression of proinflammatory cytokines, inactivates myofibroblasts and stimulates proliferation of renal epithelial cells. This review highlights the novel actions of suramin in a variety of tissues and organs.