Medication Adherence among Patient with Bipolar Disorder:

A Literature Review

Fardelin Hacky Irawani

, Weena Chanchong

, Wandee Suttharangse

Department of Psychiatric and Mental Health Nursing, Syiah Kuala University, Banda Aceh, Indonesia

Department of Psychiatric and Mental Health, Prince of Songkla University, Hatyai, Thailand

Keywords: medication adherence, medication non-adherence, bipolar disorder, medication adherence and bipolar

disorder

Abstract: Bipolar disorder is one of the chronic mental health disorders. It is ranked the seventh leading cause of non-

fatal burden in the world. Patients with bipolar disorders encounter several disturbances in their moods,

cognitions, and behaviours which express differently during mania and depressive episodes. These

difficulties can affect a patient’s life functionings, especially in regards to social functioning. Bipolar

disorder can be treated and the patients can become productive and be able to live meaningfully. However,

non-adherence with medication is common problem among patients with bipolar disorder that is associated

with elevated rates of relapse, hospitalization, suicidal behaviour, greater cost of caring, and consequently a

poor quality of life. Several factors contributed to medication adherence among patients with bipolar

disorder have been discussed including age, gender, marital status, substance abuse, phase/stage of illness,

medication knowledge, individual’s beliefs, illness representation, social support, and medication side

effects. This literature review aims to explore the importance of medication adherence to patients with

bipolar disorder and several factors influencing to medication adherence. PubMed, CINAHL, Science

Direct, Google Scholar were used to search the articles published from 2000 to 2013 in English that

combined the search terms “bipolar disorder”, “medication adherence”, “medication non-adherence”, and “

medication adherence and bipolar disorder”. In order in helping to enhance medication adherence in

patients, health care providers indeed need to understand the phenomenon of medication adherence.

INTRODUCTION

Bipolar disorder is a chronic mental health disorder

with periods of remission and relapse (Macneil,

Hasty, Conus, Berk, & Scottt, 2009). It is estimated

to be the seventh leading cause of non-fatal burden

in the world (Ayuso-Mateos, 2001). Globally, the

lifetime prevalence of bipolar spectrum disorder is

approximately 3% to 7% of the population

(Williams, Ruekert, & Lum, 2011) and

approximately 0.5% to 5% for prevalence in any

type of bipolar disorder (Vieta et al., 2011), with the

average age of onset being 15 to 30 years (Williams

et al., 2011). The prevalence of bipolar disorder in

Indonesia is unknown yet. However, based on the

Global Burden of Disease 2000 survey, the prevalence

of bipolar disorder in the sub-region SearB (South-

East Asia) in which Indonesia was included, showed

the highest number per population in the 30-44 year

age group (Chisholm, van Ommeren, Ayuso-Mateos,

& Saxena, 2005).

Despite not being ranked the first among mental

health disorders, bipolar disorder causes a significant

burden (Vieta, 2005), such as relapse, re-

hospitalization, suicidal behavior, and a greater cost

to caring (Adam & Scott, 2000; Colom, Vieta,

Tacchi, Sanchez-Moreno, & Scott, 2005; Depp,

Lebowits, Patterson, Lacro, & Jeste 2007; Sajatovic,

Bauer, Kilbourne, Vertrees, & Williford, 2006; Scott

& Tacchi, 2002) which ultimately affects

functioning in everyday life (Nieng, 2011).

Medication is one of the treatment approaches in

bipolar disorder. Thus, if individuals get the proper

medication, they would be able to regain a

productive life like others (National Institute of

Mental Health [NIMH], 2009). However, non-

adherence with medication in bipolar disorder is a

common problem (Lingam & Scott, 2002), with the

228

Irawani, F., Chanchong, W. and Suttharangse, W.

Medication Adherence among Patient with Bipolar Disorder: A Literature Review.

DOI: 10.5220/0008396800002442

In Proceedings of the Aceh International Nursing Conference (AINC 2018), pages 228-233

ISBN: 978-989-758-413-8

incident rate ranging from 20% to 60% (Berk, Berk

& Castle, 2004; Colom & Lam, 2005; Lingam &

Scott, 2002).

Medication non-adherence is associated with

elevated rates of relapse, hospitalization, suicidal

behavior, greater cost to caring (Adam & Scott, 2000;

Colom, Vieta, Tacchi, Sanchez-Moreno, & Scott,

2005; Depp, Lebowits, Patterson, Lacro, & Jeste

2007; Sajatovic, Bauer, Kilbourne, Vertrees, &

Williford, 2006; Scott & Tacchi, 2002), and

consequently a poor quality of life (Crowe, Wilson, &

Inder, 2011). Several factors contribute to

medication non-adherence among patients with

bipolar disorder including age (Baldessarini, Perry, &

Pike, 2007; Berk et al., 2010; Hou, Cleak, & Peveler,

2010), gender, marital status, substance abuse (Berk et

al., 2010; Clatworthy, Bowskill, Rank, Parham, &

Horne, 2007; Sajatovic, Bauer, Kilbourne, Vertrees,

& Williford, 2006; Sajatovic, Velligan, Weiden,

Valenstein, & Ogedegbe, 2010), phase/stage of

illness (Berk et al., 2010; Colom et al., 2005),

medication knowledge (Berk et al., 2010; Rosa et

al., 2009; Seo & Min, 2005), an individual’s beliefs

and attitude (Adams & Scott, 2000; Clatworthy et

al., 2007; Clatworthy et al., 2009; Lan, Shiau & Lin,

2003; Scott & Pope, 2002), cognitive illness

representation (Brown et al., 2001; Hou et al., 2010;

Lobban et al., 2003; Sajatovic et al., 2009a),

theurapeutic alliance (Berk et al., 2004; Lingam &

Scott, 2002), social support (Berk et al., 2010; Seo &

Min, 2005), and medication side effects (Clatworthy

et al., 2009; Patel & David, 2007; Sajatovic et al.,

2011).

In the following article, we review the literature

on medication adherence among patient with bipolar

disorder and discuss the small research based on

how the concepts are linked.

FINDINGS

2.1 Definition and Nomenclature

In the literature review, there are three terms related

to a patient’s medication taking behavior;

compliance, adherence, and concordance. In terms

of compliance and adherence, these terms reflect

different meanings in a patient’s action in taking

medication. However, some authors have often used

compliance and adherence interchangeably because

they want to shift away from negative connotation of

compliance which is coercion. Even though they used

adherence to replace compliance, however, they may

use the same measurement. For instance, in Berk’s

literature review (as cited in Berk et al., 2010), some

studies used adherence and the others used

compliance. However, among those studies, the

same measurement to measure variables of taking

medication was used.

Currently, since compliance and adherence have

different meanings, some authors have defined these

two terms. In terms of compliance, Vukovich (2010)

defined that compliance is a patient’s acceptance of

medication and other psychiatric treatment because

he/she is forced, persuaded, or pressured to take

his/her medication. In compliance, patients yield to or

obey to physicians’ instructions. It implies conformity

to medical defined goals only. Based on Seo and Min

(2005), compliance is more likely a person’s

behavior of taking medication in the correct dose,

and time as prescribed by the doctor. Based on Mullen

(as cited in Cohen, 2009), compliance implies

obedience and the expectation that patients will

passively follow the order. It refers to behavior

characterized by the extent to which people obey,

follow the instructions, or use the prescriptions

assigned by a health-care provider (Brawley &

Culos-Reed, 2000). Meanwhile, Patel and David

(2007) defined compliance is the extent to which a

person’s behavior coincides with medical advice. From

these definitions, it shows that compliance occurs

because of control or force by other people to follow

the prescriptions (external control), therefore, in this

condition, the patient is a passive patient.

Adherence, on the other hand, refers to patients’

voluntary behaviors to take their recommended

medication from their own commitment (Vukovich,

2010). Adherence is the patients’ choice to take their

medication under their own responsibility and they

can interpret their medication correctly because of

their understanding (Patel & David, 2007). It implies

that patients have their own choice to plan their

behavior to take medication and implement their

medication by their own motivation and action

(Brawley & Culos-Reed, 2000). Adherence is the

patient’s agreement to take medication and continue to

use it for a period of time (Velligan et al., 2006).

Patients’ attempts to maintain health behavior

related to behaviors to take their medication are

based on their active participation and agreement

(Cohen, 2009). Based on Lutfey and Whisner

(1999), adherence is the patients' behavior to take

their medication as independent, intelligent, and

autonomous people, therefore, the patients are

voluntary and become active participants in their

medical treatment. Furthermore, Horne (2006)

defined adherence as “the extent to which the patient’s

Medication Adherence among Patient with Bipolar Disorder: A Literature Review

229

behavior matches agreed recommendations from the

prescriber” (p. 66S).

Nevertheless, to achieve adherence, adherence

needs concordance that is emphasized on patient

decision-making and patient agreement. Vukovich

(2010) defined concordance as the agreement

between the patient and the treatment team on the

goals and means of the treatment. It implies that

concordance is a necessary way to achieve

adherence.

Medication adherence involves quite complex

behaviors reflecting an integration of a person’s

mental state such as a person’s willingness as well as

external behaviors such as the actual actions of

medication taking. Those refers to (1) patients’

behavior in taking their medication by their own

commitment/agreement (voluntarily), (2) taking

medication from their own

responsibility/plan/action/active participation as a

result of their understanding (actively), (3) taking

medication continuously for a period of time

(continuously), and (4) taking medication matching the

recommendation (taking medication correctly as

prescribed).

3.2 The Importance of Medication Adherence

Relapse prevention. Patients with bipolar disorder

who are on maintenance medication, especially

Lithium, but discontinue their medication, almost

always result in relapse, usually in weeks to months

after stopping (Peet & Harvey, 1991). A study by

Adam and Scott (2000) showed that patients who are

partially adherent are more likely to be relapsing

compared than those who are highly adherent.

Hospitalization prevention. Likewise, high

adherence to medication among patients with bipolar

disorder is more likely to result in a smaller number

of hospitalizations (Lage & Hassan, 2009; Sajatovic

et al., 2006). A study by Scott and Pope (2002)

about self-reported adherence in which psychiatric

hospitalization was one of the outcomes among

bipolar disorder patients showed that patients who

were partially adherent to medication had had a

higher number of psychiatric hospitalizations

compared to those who were fully adherent.

Reducing of symptoms severity. Taking

medication as prescribed can reduce symptoms

severity. A study by Adam and Scott (2002) showed

that patients with stronger beliefs about the benefits

of treatment were highly adherent compared with the

partially adherent subjects who had higher perceived

severity of illness scores. Moreover, individuals who

were non-adherent with prescribed medication

experienced more severe symptoms. (Sajatovic et al,

2009).

3.2 Factors Contributed to Medication

Adherence

Age. Younger aged patients were more non-adherent

than older patients, they have more negative views of

medicines, they perceive that their medicines can

harm them, and they perceive that they have more

personal control over managing themselves in relation

to their illness (Hou et al., 2010). A survey study of

429 patients with bipolar disorder related to treatment

adherence (Baldessarini et al., 2007) showed that

younger patients were more non-adherent.

Moreover, patients who received either lithium or

anticonvulsant medication were more likely to be

younger in non-adherence to medication. To sum

up, younger aged patients are more non-adherent

than older aged patients (Berk et al., 2010).

Gender. Females are more likely to be non-

adherent than males. Bipolar disorder in women is a

challenging disorder to treat because it differs with

male in various aspects, such as; women reproductive

cycle particularly postpartum, premenstrual phase of

menstrual cycle, peri-menopause, and menopause

(Parial, 2015). Sajatovic et al. (2010) in their study

about illness experience and reason for non

adherence showed that females were more likely to be

non-adherent. Similarly, Clatworthy et al. (2007)

also reported higher numbers of females for non

adherence. In additon, Kessing (as cited in Berk et

al., 2010) reported that females were significantly

more likely to have poorer adherence to lithium in a

naturalistic study in Denmark.

Marital status. There are differences results in

regards to marital status as a factor of medication

adherence. Clatworthy et al. (2007) reported that

there were no significant differences in marital status

for non adherence or adherence. Meanwhile, based on

Connely as cited in Berk et al., (2010) it appears that

marital status is a protective factor that increases

adherence. Similarly with Connely’s study,

Sajatovic (as cited in Berk et al., 2010) showed the

results that non-adherent patients were more likely

to be in the single status group. Individuals who get

married are less frequent to suffer bipolar disorder than

those who have divorced or never been married. (Aubry

et al., 2007).

Substance abuse. Individuals with bipolar disorder

who have any current substance abuse disorder will

be more likely to be non-adherent and individuals

who have any past substance use disorder showed no

significant difference between the adherence and

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non-adherence group. The most common substance

abuse was alcohol (Sajatovic et al., 2006). Moreover,

Sajatovic, et al. (2010) reported that a high number

(65 % of 13 participants with bipolar disorder) of

substance use dependents are non-adherent in

regards to prescribed medication.

Phase/Stage of illness. Adherence problems also

can happen in different phases and stages of the

illness. For example, people who have an increasing

severity of manic symptoms are at risk for adherence

problems (Keck as cited in Berk et al., 2010). Related

to this problem, Colom et al. (2005) stated that

adherence problems may be prevalent at specific

stages in the course of the illness, for example late

adherence and late non-adherence. In late adherence,

patients were in adherence after experiencing

repeated relapses. Meanwhile in late non-adherence,

patients will be in non-adherence in long-term

treatment and they will feel that their treatment is

not working well.

Medication knowledge. Having a good level of

knowledge about their illness and treatment is one of

important factors among patients with bipolar

disorder. This condition can help patients in making

decisions about illness management and negative

beliefs about medications (Berk et al., 2010). Good

knowledge about medication was found to directly

improve medication compliance (Seo & Min, 2005).

Moreover, a correlation study by Rosa et al. (2009)

that assessed medication adherence and its related

factors in patients with bipolar disorder showed that

patients’ knowledge about their disorder and

medication positively correlated with treatment

adherence to lithium prophylaxis.

Individuals’ attitude. Attitude toward medication

had a significant positive effect on medication

compliance (Lan, Shiau & Lin, 2003). A study of

Clatworthy et al. (2009) focused on patients’

attitudes to medication showed that about 30% of

patients were reported with low adherence because

of greater doubts about personal need for treatment

and stronger concern about potential negative effects.

According to Scott and Pope (2002), not easy to

accept the illness may also influence medication non

adherence.

Individual’s beliefs and cognitive illness

representation. Adams and Scott (2000) reported that

highly adherent and partially adherent subjects are

significantly different in their perception of illness

severity, their beliefs about themselves and their

control over the disorder, and their concerns about

future hospitalization. Moreover, Clatworthy et al.

(2007) assumed that patients can make decisions about

taking medication or not based on their perceptions of

the illness and treatment. A study by Hou et al.

(2010) showed that participants who were in the

non-adherence group believed that their illness

caused more negative effects on their life

(consequences) and would have a longer-term

impact (timeline). In a preliminary investigation by

Brown et al. (2001), Brown stated that a patient’s

illness cognition (i.g. timeline, consequences, and

cause) were associated with medication adherence.

In their study, they also found that poor adherence

associated with interpersonal difficulties was a cause of

depressive symptoms. In addition, patients who

perceived their illness as a mental health identity,

with negative consequences, and high levels of belief

in treatment to control symptoms were more likely to

take medication as prescribed (Lobban, Barrowclough

& Jones, 2003). An individual’s perception of risks

and benefits of medication treatment were more likely

to affect treatment adherence in bipolar populations

(Scott as cited in Sajatovic et al., 2009b).

Therapeutic alliance. Therapeutic alliance is

important for affective disorder patients (Lingam &

Scott, 2002). Lingam and Scott reported that poor

interaction between the clinician and patient was

four times more common with non-adherent patients

compared to those who were adherent. Moreover, in

Zeber’s study (as cited in Berk et al., 2010) among

veteran patients with bipolar disorder, it showed that

therapeutic alliance was positively connected to

medication adherence.

Social support. Social support has been identified as

a factor to medication adherence. Seo and Min study

(2005) found that social support is the strongest direct

effect on medication compliance. This social support

can come from family, friends and health care

professionals. Family members will also influence the

patient’s attitudes and beliefs about the illness and its

treatment, and it also can affect adherence (Cochran

as cited in Berk et al., 2009). High expressed

emotions and particularly over involvement in the

family is considered being associated with poorer

adherence and poorer overall outcomes in bipolar

patients (Miklowitz as cited in Berk et al., 2010).

Medication side effects. Medication side

effects are a common reason for non-adherence in

psychiatric patients (Scott as cited in Patel &

David,

2007). Clatworthy et al. (2009) reported that

about 30% of the participants that were in low

adherence was predicted by greater doubts about

personal need for treatment and stronger concern

about potential negative effects. Then, Sajatovic et al.

(2011) reported that the side effects of a drug were

main reason for deciding not to take the medication.

Medication Adherence among Patient with Bipolar Disorder: A Literature Review

231

DISCUSSION

As medication is important for patients with

bipolar disorder, many research studies had been

conducted for bipolar disorder to see how non-

adherent to medication can have the negative

effects to patients with bipolar disorder. Nurses and

health care professionals usually use routine care

procedures in the hospital to enhance a patient’s

medication adhrence. Usually routine care focuses on

the patient’s problems, especially problems related

to symptom management, providing education

about the patient’s medication, the frequency of

taking medication, and indications and side effects

of the medication. In the psychiatric hospital,

patients follow this routine care and take medication

because of the order from the nurse or another health

care professional. There is no known specific study

that can enhance medication adhrence, especially in

patients with bipolar disorder.

CONCLUSIONS

Medication adherence is important for patient

with bipolar disorder, to prevent relapse and re-

hospitalization, to reduce symptoms severity, to

gain a better control of mood swings and to improve

functioning and quality of life. However, in fact, non-

adherence to medication is a common problem in

the psychiatric area including patients with bipolar

disorder. Prior to helping to enhance medication

adherence in patients, health care providers indeed

need to understand the phenomenon of medication

adherence.

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