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Dr. Boyer and Colleagues Reply

To the Editor: We share with Mr. Hogarty a concern that evidence-based psychosocial interventions have not been widely implemented, despite success in improving adjustment and preventing relapse. Our review of psychosocial interventions for enhancing medication adherence in the treatment of schizophrenia was to improve management of care. We concluded that no single strategy yielded impressive results, although targeted programs using cognitive techniques that specifically targeted patients’ attitudes held much promise.

In our review, we noted that high rates of medication adherence were common in efficacy studies and, hence, that "this requirement may make it difficult to detect an increase in adherence" (p. 1661). Mr. Hogarty reinforces this point in his efforts to maximize medication adherence across groups to assess the effects of personal therapy and thus questions whether this therapy would additionally improve medication adherence. While ceiling effects limit opportunities to achieve group differences, we would like to inquire whether the interventions studied yield additional benefits for adherence. Efficacy studies are important, but a large gap remains between efficacy studies under controlled conditions and effectiveness studies in practice, where multifaceted intervention strategies must be evaluated against usual care. The literature also makes an increasingly compelling case that in achieving specifically desired outcomes, such as medication adherence or employment, targeted efforts are more effective than more diffuse ones (1). Psychoeducational efforts might usefully incorporate specific interventions directed at medication adherence. This was, in fact, what Mr. Hogarty and his colleagues did across conditions to optimize adherence (Hogarty et al., 1997).

We are grateful to Dr. Hamann and his colleagues for directing us to the eight-session psychoeducational intervention study recently reported in the German literature (Basan et al., 2000). Appropriately applied quantitative meta-analytic procedures can yield information not readily apparent from a structured literature review. At the time of our review, the literature was not sufficiently developed to support a formal meta-analysis.

We share with Dr. Hamann and co-workers an interest in studying patient involvement in clinical decision making. Educating patients to become more actively engaged in their care has been demonstrated to improve outcomes in chronic diseases (2) and may prove valuable in the care of schizophrenia as well.

References

1. Bond GR, Becker DR, Drake RE, Rapp CA, Meisler N, Lehman AF, Bell MD, Blyler CR: Implementing supported employment as an evidence-based practice. Psychiatr Serv 2001; 52:313–322[Abstract/Free Full Text]
2. Monninkhof E, van der Valk P, van der Palen J, van Herwarrden C, Partridge MR, Zielhuis G: Self-management education for patients with chronic obstructive pulmonary disease: a systematic review. Thorax 2003; 58:394–398[Abstract/Free Full Text]

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