Features of adherence to medical regimes

Aim: To review research on the impact of being diagnosed with hypertension (high blood pressure), the effects of treatment and the factors influencing withdrawal from treatment.

Background: The main treatment for high blood pressure is to take diuretic drugs and to make lifestyle changes such as stopping smoking and drinking alcohol, reduce weight and reduce intake of salt and fat. This can make a patient feel a loss of wellbeing. 

Sample: This review article reports on four surveys, a Medical Research Council (MRC) drug trial and various other studies. The data in the four surveys comes from 78 undiagnosed people who represent the baseline data against which to compare the responses of nearly 600 patients referred to doctors but not yet treated and over 800 treated patients.

Method: Data was collected with self-administered questionnaires. In addition, some measures of urine sodium level excretion were taken to check if patients had in fact reduced their salt intake. The MRC drugs trial followed a randomised, single-blind format.

Results:The major reason people stopped treatment was the side effects; over the five years of the MRC trial, 15% withdrew with gout and impotence symptoms. Depression, lethargy and dizziness were also frequently reported. Labelling a patient as hypertensive had an effect on work and leisure by increasing absenteeism and increasing anxiety and patients were less likely to take part in hobbies due to tiredness and lethargy induced by the drug treatments.

Evaluation: A review article gives a wealth of data which covers several countries and gives a holistic picture of the effects of takinga medication for hypertension. No two studies use the same methods so it could be difficult to test for reliability. Survey data could have problems with accuracy of memory and social deserability with patients exaggerating or minimising side effects of the drugs to be 'good' patients. Psychology as a science - using results from randomised single blind drugs trials and incorporating with more quantitative data gives a rigorous picture. The findings should help medical practitioners be aware of the likely difficulties male patients in particular will have in taking these medications.

Aim: To find out if treating depression in patients with diabetes with fluoxetine would work to help patients control their blood suger levels and maintain their medication more effectively.

Background: Evidence suggests that the presence of diabetes doubles the risk of having depression and affects more than a quarter of people suffering from diabetes. Diabetic patients who are depressed are less likely to manage their condition well. 

Sample: 60 patients aged 21 -65 years wh met the diagnostic criteria for major depression. Each had a score of 14 or greater on the Beck Depression Inventory (BDI) or the Hamilton Rating Scale for Depression (HAMD). They had either Type 1 or Type 2 diabetes.

Methods: In the double-blind placebo-controlled study patients were randomly assigned to receive fluoxetine, which was initiated at a dosage of 20 mg per day and increased up to 40 mg daily as required by the clinical response. Depression and glycaemic control were evaluated during the third, fifth and eighth weeks of treatment.

Results: 54/60 patients (27 in each group)  completed the study. After 8 weeks of fluoxetine therapy, depression scores had dropped significantly, from a mean BDI score of 23.6 to 9. In the placebo group, the mean BDI scores were 22.4 and 13.6 at baseline and after treatment, respectively. Improvement in HbAIc (blood glucose) level was greater in the fluoxetine group than in the placebo group, but the difference wasn't statistically significant. The mean decrease in HbAIc was 0.40% in the fluoxetine group and 0.07% in the placebo group. This shows a positive trend after 8 weeks of treatment.

Evaluation: A combination of psychometric test measures and blood tests makes the findings reliable. This was a small sample and results were taken after a relatively short time when it is well known that anti-depressants take some time to work. This is a rigous design which restricts any bias. This is a reductionist approach using alteration in brain chemistry through drugs to treat depression rather than looking at the whole lifestyle of the patient. Provides evidence that adherence to a physical treatment could be affected by mental factors.

Aim: To see if inserting a fun device in an inhaler would improve adherence to the device by children.

Background: Poor adherence to taking their asthma medication is a problem for children with as few as 39% of children using their inhalers correctly and getting the right dose. This leads to more hospitalisations and greater risk of a very serious attack.

Sample: 32 children (10 male, 22 female) aged 1.5 - 6 years with on average two years suffering from asthma.

Method: Data was collected by questionnaire two weeks after using the devices and they were completed by the parents. The incentive toys (a whistle or a spinner) were incorporated into the inhaler in a design which avoided any risk of contamination and which were intended to distract the child from the medication while as the same time encouraging the big breath needed to take in the drugs.

Results: An increase in use of 38% was reported, with more children likely to take the four cycles of delivery than with the standard device. The device was not affected by the insertion of the spacer and the same amount of medication was available in each 'puff'.

Evaluation: Collecting the data by questionnaires from parents could reveal a tendency to wish to report more use than actually happened, showing social desirability. Why only 38% improvement? This small sample of only 32 children is not very generalisable. Difficulties with adherence to medical advice could be affected by culture so this research could be ethnocentric. Asthma is a western illnes rarely found in the less developed world. A simple improvement which had a rapid effect at a very little cost and showed a different approach was needed to get children to comply with medical advice.