Factors Associated With Pharmacological and Non-pharmacological Treatments Adherence in Patients With Borderline Personality Disorder in Iran

BackgroundBorderline personality disorder is a major mental illness characterized by a sustained relationship instability, impulsive behavior and intense affects. Adherence is a complex behavior, from minor refusals of treatment to inappropriate use of health services or even abandonment of treatment, which can be affected by various factors. Therefore, the present study aimed to investigate the factors affecting pharmacological and non-pharmacological adherence in patients with borderline personality disorder referred to an outpatient referral clinic in Tehran, Iran.MethodsThe study was a retrospective cohort. The files of patients with borderline personality disorder referred to the outpatient clinic of the Tehran Psychiatric Institute were reviewed as the first step. In the next step, we contacted the patients and asked them to fill out the questionnaires. Data were collected using the Drug Attitude Inventory (DAI) questionnaire and a researcher made questionnaire to determine the attitude of patients toward pharmacological and non-pharmacological treatment and therapeutic adherence. After collecting data, patients’ therapeutic acceptance was divided into three groups: poor, partial, good compliance. The data were analyzed by SPSS software version-22.Results Ninety-four patients were involved in the study and fifty four of them were women. In terms of psychotherapy adherence, patients with higher education and hospital admission history have better compliance. Medication attitudes were negative in 54 patients (57.4%), while 40.4% of them stated that psychotherapy or counselling did not help their condition and showed a negative attitude toward non-pharmacological treatment. Additionally, psychotherapy good adherence of the patients (44.7%) was higher than medication good adherence (31.9%). The most common reasons for discontinuation of treatment were medication side effects (53.1%), dissatisfaction with the therapist (40.3%) and then fear of medication dependence (40%). The results showed no relationship between other demographic factors and treatment adherence.ConclusionsResults of the current study show that attitude toward psychotherapy is more positive than pharmacotherapy. In addition, according to the results, working on changeable factors such as patients’ fear of dependence to medication, dissatisfaction with the therapist, and medication side effects may improve patients' treatment adherence.

The biopsychosocial-spiritual factors influencing relapse of patients with schizophrenia

Objective: High relapse rate of patients with schizophrenia has a large impact on patients and their families that can be reviewed from biopsychosocial and spiritual factors. Determining all the potential risk factors of relapse in schizophrenia can help increase awareness of physicians, patients, and families. Physicians are the ones who examine patients and have responsibility to manage and educate them and expect to prevent relaps. This study analyze various biopsychosocial and spiritual factors affecting relapse occurrence in patients with schizophrenia. Methods: Cross sectional observational analytic study on 226 subjects with schizophrenia in three places in East Java, Indonesia, namely Soetomo Academic Hospital Surabaya (33.2%), Menur Hospital Surabaya (32.7%), and Radjiman Wediodiningrat Mental Hospital Lawang (34.1%) that met the inclusion and exclusion criteria. Data collection including 33 biopsychosocial and spiritual factors and were analyzed using bivariate and multivariate logistic regression. Results: Relapse rate within 1 year was 59.73%. There were 12 factors significantly affected the relapse of schizophrenia, namely history of physical disease of mothers during pregnancy ( p < .001; B = 27.31; 95% CI 3.96–188.52), presence of trigger ( p < .000; B = 6.25; 95% CI 2.61–14.96), negative beliefs ( p < .000; B = 4.94; 95% CI 2.10–11.61), hereditary factors ( p < .001; B = 4.84; 95% CI 1.93–12.10), insight ( p < .003; B = 4.27; 95% CI 1.62–11.27), 1-year GAF Scale ( p < .015; B = 3.79; 95% CI 1.30–11.09), response to treatment ( p < .006; B = 3.68; 95% CI 1.45–9.36), family knowledge ( p < .011; B = 3.23; 95% CI 1.31–7.93), history of head trauma ( p < .029; B = 3.13; 95% CI 1.13–8.69), medication side effects ( p < .028; B = 2.92; 95% CI 1.12–7.61), substance use history ( p < .031; B = 2.86; 95% CI 1.10–7.45), and occupation ( p < .040; B = 2.40; 95% CI 1.04–5.52). Conclusions: The 12 factors of biopsychosocial-spiritual are determinant to predict the risk of relapse in patients with schizophrenia. These factors should be emphasized in psychoeducation for patients and their families to enable intervention and relapse prevention.

Sexual Dysfunction in Schizophrenia: A Narrative Review of the Mechanisms and Clinical Considerations

Psychiatric disorders, in general, have a high prevalence of sexual problems, whether from the psychopathology of the disorder itself, pre-existing or co-morbid sexual disorder or from side effects of the treatment for mental disorders. Many patients report an already existing sexual dysfunction at the onset of diagnosis. The risk association for developing sexual dysfunction in patients with schizophrenia includes antipsychotic use and resulting hyperprolactinemia, age, gender, and disease severity. Medication side effects lead to nonadherence, and relapses lead to structural changes in the brain, treatment resistance, and worsening of symptoms. Findings in certain studies propose serum prolactin and thyroid-stimulating hormone measurement as a tool for assessing patients with schizophrenia for sexual dysfunction. Regarding specific symptoms, females especially reported decreased desire at baseline and galactorrhea after treatment. The findings of this review, therefore, suggest that sexual dysfunction may be present in patients with schizophrenia before starting antipsychotic treatment and that patients, especially those who are female, are likely to develop hyperprolactinemia with antipsychotic treatment. Aripiprazole may be an emergent treatment for sexual dysfunction in those who use antipsychotics. It is important for patients to consider sexual dysfunction prior to prescribing antipsychotics. Since sexual dysfunction can impact a patient’s quality of life and affect treatment adherence, it is important for physicians to be aware and monitor patients for symptoms.

Family Caregiver Burden of Medication Administration for Older Adults Admitted to Home Hospice

Objective: To characterize FCG burden of medication administration for older adults in home hospice. Methods: Pilot clinical trial of a hospice-staff level communication and medication review program to facilitate goal-concordant prescribing, including deprescribing, for older adults in home hospice. Patients newly admitted to hospice were eligible if &gt;=65 years, prescribed &gt;= 5 medications and had a FCG. Exclusion criteria included being non-English speaking or having a Palliative Performance Score&lt;40. Measurements include 24-item FCG Medication Administration Hassle Scale (range 0-96) at hospice admission and at 2-, 4-, 6-, 8-weeks and monthly until death. Descriptive statistics characterize baseline FCG Hassle score. Results: In this actively recruiting study, n=9 patient-caregiver dyads are enrolled to date. Mean patient age is 80.6 years (range 69-101). Of 9 caregivers, 7 were female, 5 children, and 3 spouses. The majority (67%) of caregivers were extremely involved in medication management. Mean FCG Hassle Score =17.1 (SE 5.9; range 2-58), and differed between spouses (mean =5 [SE 1.7; range 2-8]) and children (mean =31.4 [SE 9.53; range 3-58]). The highest burden concern was recognizing medication side effects, followed by feeling comfortable making medication decisions, arguing with the care-recipient about when to take medications, knowing why a medication is being given and whether it is effective, and knowing when to hold, increase, decrease a dose or discontinue the medication. Conclusion: FCGs of older adults in home hospice report different levels of medication administration hassle depending on their relationship to the patient. The most bothersome concern is recognizing medication side effects.

Learning best practices for educating a caregiving workforce

It is well established that the health professional workforce is not adequately prepared to meet the demands of an aging older population. Caregivers are often the backbone supplemental workforce for seniors, providing daily care with assistance with activities of daily living, with little training. Part of the mission of the South Florida Geriatric Workforce Enhancement Program (SFGWEP) is to support and empower caregivers through community based training programs. Between January 1 2020 to January 31, 2021 SFGWEP provided education to more than 340 caregivers on topics related to opioid use, effective communication with individuals with dementia and other topics. Attendees responded to a short evaluation survey, which included three multiple-choice questions on if attending was a good use of their time, if they gained knowledge and if they plan to apply material, and two open-ended questions to identify opportunities for improvement in future trainings. Responses were overwhelmingly positive (&gt;98% for multiple-choice questions.) There were also three open-ended questions that were analyzed using a modified thematic approach. The three questions covered what attendees learned, what they wanted to learn more about and suggestions for improvement. Analysis suggests that attendees plan to be more mindful about communication (e.g. improve eye contact, listen more) and that they want more information on neurocognitive disorders and resent research, including psychological changes due to disease and medication side effects. In terms of improvement, attendees said the program should allow more time for questions and should use more engaging materials (polls, posters, flyers and case studies).

Dose Reductions Related to Adverse Effects in Patients with Waldenström Macroglobulinemia Treated with the BTK-Inhibitor Ibrutinib

The BTK-inhibitor ibrutinib is the first FDA approved therapy for Waldenström macroglobulinemia (WM) and produces overall response rates &gt;90% and long-term disease control in both treatment naïve and previously treated patients. Despite the remarkable efficacy of ibrutinib, dose reduction is often required for intolerance. In this study, we analyzed those patients requiring a dose reduction and evaluated the time to dose reduction, the symptoms leading to dose reduction, the rate of improvement in symptoms after dose reduction, and the hematologic response at 12 months after dose reduction. 385 patients received treatment with ibrutinib in our clinic from May 2012 through October 2020. Their baseline characteristics are shown in Table 1. Starting dose for these patients was 560 mg (n=11); 420 mg (n=358); 280 (n=15); 140 mg (n=1). Approximately 1/3 of all patients were treatment naïve at the time ibrutinib was initiated. Anemia, constitutional symptoms, and symptomatic hyperviscosity (or risk of hyperviscosity) were the most common reasons for treatment initiation. Reasons for dose reduction are shown in Table 2. Ninety-five patients (25%) required at least one dose reduction of ibrutinib. Twenty-three patients (6%) required a second dose reduction. Of the patients requiring dose reductions, 1 patient started at 280 mg and reduced to 140 mg, 91 patients started ibrutinib at 420 mg (1 patient ultimately had dose reduction to 70 mg, 22 patients to 140 mg, and 68 patients to 280 mg), and three patients started ibrutinib at 560 mg in the setting of Bing-Neel syndrome (2 patients had dose reduction to 420 mg and 1 patient to 280 mg). Patients requiring a dose reduction had a median age of 71 years (range, 46-96) at the time of ibrutinib initiation versus 66 years (range, 40-93) for those not requiring a dose reduction (p&lt;0.001). Forty-five patients (47%) of patients requiring dose reduction were female versus 98 (34%) not requiring dose reduction (p=0.017). Median time to first dose reduction was 7.3 months (range, 0.5-75) and median time to second dose reduction from initiation of ibrutinib was 23 months (range, 3-75). Of the 95 patients requiring a dose reduction, 40 patients (42% of all patients with dose reductions) had improvement in at least 1 of the medication side effects after the initial dose reduction. Twenty-two patients (23%) had complete resolution of adverse effects. Twenty-six patients (27%) had no change in symptoms and 10 of these patients required an additional dose reduction. After the second dose reduction, 5 patients had improvement or resolution in symptoms. Two patients had no adverse effects prior to dose reduction and medication was reduced simply due to drug interaction. Of the 48 patients with 1-year hematologic follow-up data available, 10 patients (21%) had improvement in hematologic response and 35 patients (73%) maintained their hematologic response despite dose reduction. Three patients (6%) had worsening of hematologic response after dose reduction. In conclusion, one quarter of WM patients in this series on ibrutinib required a dose reduction due to development of intolerable medication side effects. In the majority of these patients, adverse effects improved or resolved with dose reduction. Importantly, hematologic response remained stable or improved in most patients despite dose reduction. Figure 1 Figure 1. Disclosures Treon: BeiGene: Consultancy, Research Funding; Eli Lily: Research Funding; Abbvie/Pharmacyclics: Consultancy, Research Funding. Castillo: Abbvie: Consultancy, Research Funding; BeiGene: Consultancy, Research Funding; Pharmacyclics: Consultancy, Research Funding; Janssen: Consultancy; Roche: Consultancy; TG Therapeutics: Research Funding.

Strategies to Improve Immune Suppression Post-Liver Transplantation: A Review

Since the first liver transplantation operation (LT) in 1967 by Thomas Starzl, efforts to increase survival and prevent rejection have taken place. The development of calcineurin inhibitors (CNIs) in the 1980s led to a surge in survival post-transplantation, and since then, strategies to prevent graft loss and preserve long-term graft function have been prioritized. Allograft rejection is mediated by the host immune response to donor antigens. Prevention of rejection can be achieved through either immunosuppression or induction of tolerance. This leads to a clinical dilemma, as the choice of an immunosuppressive agent is not an easy task, with considerable patient and graft-related morbidities. On the other hand, the induction of graft tolerance remains a challenge. Despite the fact that the liver exhibits less rejection than any other transplanted organs, spontaneous graft tolerance is rare. Most immunosuppressive medications have been incriminated in renal, cardiovascular, and neurological complications, relapse of viral hepatitis, and recurrence of HCC and other cancers. Efforts to minimize immunosuppression are directed toward decreasing medication side effects, increasing cost effectiveness, and decreasing economic burden without increasing the risk of rejection. In this article, we will discuss recent advances in strategies for improving immunosuppression following liver transplantation.

Self-Reported Effects of Cannabis on ADHD Symptoms, ADHD Medication Side Effects, and ADHD-Related Executive Dysfunction

Objective: People with ADHD are more likely to use cannabis but little is known about the effects of cannabis on ADHD symptoms, ADHD medication side effects, or ADHD-related executive dysfunction. Method: Students ( n = 1,738) completed an online survey containing measures of ADHD symptoms, cannabis use, perceived effects of cannabis on ADHD symptoms and medication side effects, as well as executive dysfunction. Results: Participants with ADHD who have used cannabis reported that cannabis has acute beneficial effects on many symptoms of ADHD (e.g., hyperactivity, impulsivity). Further, they perceived cannabis to improve most of their medication side effects (e.g., irritability, anxiety). Finally, cannabis use frequency was a significant moderator of the associations between symptom severity and executive dysfunction. Conclusion: Results suggest people with ADHD may be using cannabis to self-medicate for many of their symptoms and medication side effects and that more frequent use may mitigate ADHD-related executive dysfunction.

Reasons for antihypertensive medication nonadherence influence physician preferences for hypertension management

Background/Introduction Patient nonadherence to prescribed antihypertensive medications is a major contributor to low global hypertension control rates. Attitudes toward renal denervation vary between physicians and patients, with recent data showing that side effects from medications is a key factor influencing both patient nonadherence to prescribed medications and preferences for interventional treatment. The influence of patient nonadherence on physician recommendations for renal denervation is not well understood. Purpose To examine whether specific reasons for patient nonadherence influence physician preferences for renal denervation as a treatment option for hypertension. Methods Online surveys were fielded to general and interventional cardiologists in Europe and the United States. Physicians were asked to position their willingness to recommend renal denervation in the hypertension management pathway based on three factors of nonadherence: patients' preference not to take antihypertensive medications, medication side effects, and nonspecific nonadherence to medication. The surveys followed the highest industry standards ISO 20252. Results were compared using two-tailed Z tests. Results Over two-thirds of 501 physicians surveyed stated that they would recommend renal denervation for uncontrolled hypertension irrespective of the reason for nonadherence. This recommendation was significantly more common in the scenario of patient reported medication side effects as compared with desire not to take medications or other nonspecific reasons for nonadherence (p&lt;0.001 for both; Figure) Conclusions Surveyed physicians were more likely to recommend renal denervation to patients reporting side effects with their antihypertensive medications than for other reasons of nonadherence. These findings underscore the influence of patient-specific reasons for medication nonadherence on provider recommendations as part of a shared decision-making process when evaluating different options for hypertension management. FUNDunding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Medtronic