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Medication Adherence Studies in Schizophrenia

To the Editor: Dr. Zygmunt and co-workers concluded that psychoeducation and family interventions without accompanying behavioral components and supportive services are not likely to improve medication adherence. If one seriously wishes to evaluate an intervention such as psychoeducation, one should not only carry out a review but also follow quantitative meta-analytic procedures. At a minimum, one should discuss published meta-analyses that document that these interventions can improve compliance and reduce readmission rates (1–3). Results of reviews or meta-analyses regarding psychoeducation naturally strongly depend on the definition of "psychoeducation" and, therefore, on the kind of studies included.

According to a generally recognized definition, psychoeducation does not merely mean doctors imparting information about medication. It is also necessary for therapists and participants to work together closely on an illness concept, which then creates a basis for compliant behavior. In group discussions, patients’ needs and doubts are addressed. They should be in a position to make an informed decision themselves on their treatment.

Thus, we were able to show in a randomized trial involving 236 schizophrenia patients (4) that a relatively brief intervention of eight psychoeducational sessions with systematic family involvement in simultaneous groups (but without explicit behavioral components) can improve compliance and reduce rehospitalizations of schizophrenia patients significantly.

We think that empowering patients contributes considerably to the success of psychoeducation. This fact is emphasized also by some studies cited by Dr. Zygmunt et al. and is, most important, one of the first results of a concept of integrating patients in medical decisions ("shared decision making") (5). Here patients should be optimally informed that they can make evidence-based treatment choices with their doctors. The implementation of this concept in psychiatry might improve treatment adherence through improved patient involvement.

Since no data on the efficacy of this concept in schizophrenia treatment are yet available, we are currently preparing a study in which patients are involved in important treatment decisions to examine the effect of a cooperative decision on treatment adherence. Further evaluations should therefore take into account the degree to which patients are involved in therapeutic decisions.

References

1. Mari JJ, Streiner DL: An overview of family interventions and relapse on schizophrenia: meta-analysis of research findings. Psychol Med 1994; 24:565–578[Abstract/Free Full Text]
2. Pekkala E, Merinder L: Psychoeducation for schizophrenia. Cochrane Database Syst Rev 2002; 2:CD002831[Abstract/Free Full Text]
3. Pitschel-Walz G, Leucht S, Bauml J, Kissling W, Engel RR: The effect of family interventions on relapse and rehospitalization in schizophrenia—a meta-analysis. Schizophr Bull 2001; 27:73–92
4. Basan A, Pitschel-Walz G, Bauml J: Psychoedukative Gruppen bei schizophrenen Patienten und anschließende ambulante Langzeitbehandlung. Fortschr Neurol Psychiatr 2000; 68:537–545[Medline]
5. Charles C, Gafni A, Whelan T: Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 1997; 44:681–692

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